Urology Book

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Urinary Tract Infection

Aka: Urinary Tract Infection, UTI, Bladder Infection, Acute Cystitis
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  1. See Also
    1. UTI in Pregnancy
    2. UTI in children
    3. Urinary Tract Infection in Men
    4. Elderly with Urinary Tract Infections
    5. Urinary Catheter associated UTI
    6. Recurrent UTI
  2. Causes
    1. Normal Host
      1. Escherichia coli (80-86%)
      2. Staphylococcus saprophyticus (10-15% of young women, 4% overall)
        1. More aggressive and recurrent infections
        2. Associated with Pyelonephritis
      3. Klebsiella (3%)
      4. Proteus (3%)
    2. Nephrolithiasis associated infection
      1. Proteus (urease positive)
      2. Klebsiella
    3. Sexually Transmitted Diseases
      1. Chlamydia
      2. Neisseria gonorrhoeae
      3. Herpes Simplex Virus II (Genital Herpes)
  3. Risk factors
    1. Sexually active women
    2. Men with Prostatitis or BPH
    3. Pregnancy
    4. Urinary Tract Obstruction
    5. Neurogenic Bladder dysfunction
    6. Vesicoureteral reflux
  4. Symptoms
    1. Most suggestive of Urinary Tract Infection
      1. Dysuria (Likelihood Ratio 2.0)
        1. If absent, Likelihood Ratio 0.5
      2. Urinary Frequency (Likelihood Ratio 1.8)
      3. Hematuria (Likelihood Ratio 1.5)
        1. Occurs in 30% of cases
    2. Other symptoms with Urinary Tract Infection
      1. Urinary Urgency
      2. Suprapubic Pain (especially after voiding)
  5. Differential Diagnosis: See Dysuria
    1. Urethritis
      1. Pain at onset of urination
    2. Vaginitis
      1. External Dysuria
      2. Vaginal irritation or discharge
    3. Chlamydia trachomatis
      1. Long, insidious onset
      2. Sexually active
    4. Acute Pyelonephritis
      1. Fever, flank pain, and Nausea or Vomiting
      2. Risk factors for cystitis with occult Pyelonephritis
        1. Women (30% have subclinical Pyelonephritis)
        2. Pregnancy
        3. Diabetes Mellitus
        4. Immunocompromised patients
        5. Urinary Tract Infection under age 12 years
        6. Genitourinary comorbid condition
  6. Labs
    1. Women with classic UTI symptoms do not need testing
      1. Criteria: UTI symptoms and no vaginal complaints
      2. Treat without Urinalysis and Urine Culture
        1. Pretest probability of UTI based on symptoms: 90%
        2. Probablity of UTI with negative Urinalysis: 23%
      3. Reference
        1. Bent (2002) JAMA 287:2701-10
    2. Urinalysis
      1. Urine Leukocyte Esterase (high Test Sensitivity but low Test Specificity)
      2. Urine Nitrite (high Test Specificity, but low Test Sensitivity)
      3. Urine White Blood Cells on microscopy
    3. Urine Culture
      1. Recommended in complicated UTI or suspected Pyelonephritis
      2. Positive for >100k organisms
      3. Women with Dysuria have <100k organisms in 30% cases
  7. Diagnosis: Factors suggestive of complicated UTI
    1. Extremes of age (preadolescent, or post-Menopause)
    2. Chronic renal disease
    3. Diabetes Mellitus
    4. Immunodeficiency
    5. Pregnancy
    6. Recent Urinary Tract Instrumentation
      1. Ureteral Stents
      2. Indwelling catheters
    7. Urologic abnormalities
      1. Nephrolithiasis
      2. Neurogenic Bladder
      3. Polycystic Kidney Disease
  8. Diagnosis: Prediction Rule
    1. Criteria
      1. New onset frequency and Dysuria
      2. Absent Vaginal Discharge and irritation
    2. Efficacy
      1. Positive Predictive Value: 90%
  9. Management
    1. General measures in women
      1. Women should clean perineum wiping front to back
      2. Women should empty Bladder before, after intercourse
      3. Avoid Contraceptive Diaphragm
    2. Antibiotics
      1. Course: Anticipate symptom relief within 36 hours of starting antibiotics
      2. Antibiotic duration
        1. Uncomplicated treatment: 3 days (except noted)
          1. Nitrofurantoin and Macrobid course is 5 days (was 7 days)
        2. Complicated treatment: 10-14 day course
      3. Antibiotic Resistance increasing
        1. Trimethoprim Sulfamethoxazole (Septra): 18%
        2. Beta Lactams: 20%
        3. Ampicillin: 38%
        4. Nitrofurantoin resistance low (1-2%)
        5. Fluoroquinolone resistance low (2.5%)
          1. Avoid as first line agents if possible
          2. Consider in areas of high Septra resistance areas
      4. Cure may occur despite resistance to antibiotic used
      5. Risks for resistance
        1. Trimethoprim Sulfamethoxazole within last 3-6 months
        2. Diabetes Mellitus
        3. Recent hospitalization
        4. Travel outside United States
        5. Resistance rates in community >20%
    3. Acute Uncomplicated UTI: First-Line agents
      1. Bactrim DS one orally twice daily for 3 days
        1. Avoid if local resistance rate >20%
      2. Nitrofurantoin (Macrobid) one orally twice daily for 5 days
        1. Avoid if GFR <60 ml/min
      3. Fosfomycin (Monurol) 3 grams for one dose
    4. Acute Uncomplicated UTI with risks for resistance (prior Bactrim use or international travel in last 6 months)
      1. Nitrofurantoin 100 mg orally four times daily for 5 days
      2. Macrobid 100 mg orally twice daily for 5 days
        1. Five days is sufficient course (previously used for 7 days)
        2. Gupta (2007) Arch Intern Med 167(20):2207-12
      3. Fosfomycin (Monurol) 3 grams for one dose
      4. Also see Fluoroquinolones below
    5. More severe disease or resistant UTI organisms: Fluoroquinolones
      1. Precautions regarding Fluoroquinolones
        1. Avoid if local resistance rate >10%
        2. Renal dose adjustment required if GFR reduced
        3. Although 3 day courses are listed, complicated UTI is typically treated for 7-14 days (up to 6 weeks in men)
      2. Ciprofloxacin 250 mg PO bid for 3 days
        1. In healthy older women, 3 days equivalent to 7 days
        2. Vogel (2004) CMAJ 170:469-73
      3. Norfloxacin 400 mg PO bid for 3 days
      4. Ofloxacin 200 mg PO bid for 3 days
      5. Avoid Moxifloxacin and gemifloxacin (poor penetration into urine)
    6. Antibiotics for UTI in Pregnancy
      1. See Urinary Tract Infection in pregnancy
    7. Other antibiotics used in Urinary Tract Infection
      1. Precautions
        1. Beta lactams have lower efficacy in UTI
      2. Cephalexin (Keflex) 250-500 mg PO qid
      3. Augmentin 875 mg orally twice daily
    8. Sexually active young patients
      1. Avoid Nitrofurantoin (Macrobid)
        1. Staphylococcus saprophyticus resistance
      2. Consider Chlamydia sceening
      3. Consider other Sexually Transmitted Disease Testing
  10. Management: Recurrent episodes
    1. See Recurrent Urinary Tract Infection
  11. Management: Asymptomatic Bacteriuria
    1. Indications for routine screening and antibiotics
      1. Asymptomatic Bacteriuria in Pregnancy
    2. Cases in which screening, antibiotics are not indicated
      1. Asymptomatic Bacteriuria in non-pregnant women
      2. Urinary Catheter Associated Asymptomatic Bacteriuria
      3. Asymptomatic Bacteriuria in Diabetes Mellitus
      4. Asymptomatic Bacteriuria in Spinal Cord Injuries
      5. Asymptomatic Bacteriuria in Older patients
    3. References
      1. Colgan (2006) Am Fam Physician 74(6):985-90
      2. Nicolle (2005) Clin Infect Dis 40:643-54
  12. References
    1. Colgan (2011) Am Fam Physician 84(7): 771-6
    2. Ebell (2006) Am Fam Physician 73:293-6
    3. Gupta (1999) JAMA 281:736-8
    4. Hooton (1997) Infect Dis Clin North Am 11:551-81

Urinary tract infection (C0042029)

Definition (NCI) A bacterial infectious process affecting any part of the urinary tract, most commonly the bladder and the urethra. Symptoms include urinary urgency and frequency, burning sensation during urination, lower abdominal discomfort, and cloudy urine.
Definition (NCI) A disorder characterized by an infectious process involving the urinary tract, most commonly the bladder and the urethra.
Definition (MEDLINEPLUS)

The urinary system consists of the kidneys, ureters, bladder and urethra. Infections of the urinary tract (UTIs) are the second most common type of infection in the body. You may have a UTI if you notice

  • Pain or burning when you use the bathroom
  • Fever, tiredness or shakiness
  • An urge to use the bathroom often
  • Pressure in your lower belly
  • Urine that smells bad or looks cloudy or reddish
  • Less frequently, nausea or back pain

If you think you have a UTI, it is important to see your doctor. Your doctor can tell if you have a UTI by testing a sample of your urine. Treatment with medicines to kill the infection will make it better, often in one or two days.

NIH: National Institute of Diabetes and Digestive and Kidney Diseases
Definition (CSP) infections affecting stuctures participating in the secretion and elimination of urine: the kidneys, ureters, urinary bladder and urethra.
Definition (MSH) Inflammatory responses of the epithelium of the URINARY TRACT to microbial invasions. They are often bacterial infections with associated BACTERIURIA and PYURIA.
Concepts Disease or Syndrome (T047)
MSH D014552
ICD9 599.0
ICD10 N39.0
SnomedCT 266635000, 155897002, 197930008, 274110008, 68566005, 197924008, 155896006, 266634001
English Urinary tract infection, Infection, Urinary Tract, Infections, Urinary Tract, Tract Infection, Urinary, Tract Infections, Urinary, Urinary Tract Infections, Urinary tract infection, site not specified, INFECTION URINARY TRACT, URINARY TRACT INFECTION, UTI, Urinary tract infections, Urinary tract infection, NOS, Urinary tract infectious disease, NOS, Infection of urinary tract, Urinary tract infect.unsp.NOS, Urinary tract infection, site not specified NOS, URINARY TRACT INFECT, Urinary infection NOS, urinary tract infection (diagnosis), urinary tract infection, uti, Urinary tract infection (& [NOS]) (disorder), Infection urinary tract, Urinary tract infection NOS, Urinary infection, Urin tract infection NOS, Urinary tract infection, site not specified NOS (disorder), Urinary infection NOS (disorder), INFECTION, URINARY TRACT, TRACT, INFECTION OF URINARY, Urinary Tract Infections [Disease/Finding], urinary tract infection (UTI), utis, urinary tract infections, urinary infection, Urinary Tract Infection, Urinary tract infectious disease, UTI - Urinary tract infection, Urinary tract infectious disease (disorder), infected; urinary, infection; urinary tract, urinary; infection, urine; infected, Infection - urinary NOS, Urinary tract infection (& [NOS]), Urinary tract infection; site not specified
Italian Infezione delle vie urinarie, Infezione urinaria, Infezione delle vie urinarie NAS, Infezione delle vie urinarie, sito non specificato, Infezioni delle vie urinarie
Dutch urinaire infectie, urineweginfectie, op niet-gespecificeerde plaats, urineweginfectie NAO, infectie van de urinewegen, geïnfecteerd; urine, infectie; urinewegen, urine; geïnfecteerd, urine; infectie, Urineweginfectie, lokalisatie niet gespecificeerd, urineweginfecties, urineweginfectie, Infectie, urineweg-, Urineweginfectie
French Infection des voies urinaires SAI, IVU, Infection urinaire, Infection des voies urinaires, site non précisé, Infection des voie urinaires, INFECTION DE L'APPAREIL URINAIRE, Infection du tractus urinaire, Infections des voies urinaires, Infections urinaires
German Infektion der Harnwege, Harnwegsinfektion NNB, Harnwegsinfektion, Stelle nicht bekannt, UTI, HARNWEGSINFEKT, Harnwegsinfektion, Lokalisation nicht naeher bezeichnet, Harnwegsinfektion, Harnwegsinfektionen
Portuguese Infecção das vias urinárias, Infecção das vias urinárias NE, Infecção das vias urinárias de localização NE, Infecção urinária, INFECCAO DO TRACTO URINARIO, Infecções do Sistema Urinário, Infecção do tracto urinário, Infecções das vias urinárias, Infecções Urinárias
Spanish Infección del tracto urinario, localización no especificada, Infección urinaria, Infección del tracto urinario NEOM, ITU, Infection - urinary NOS, Infection of urinary tract, Urinary tract infection, Urinary tract infection (& [NOS]), Urinary tract infection, site not specified, Urinary infection NOS, Urinary tract infection NOS, INFECCION VIAS URINARIAS, enfermedad infecciosa de las vías urinarias, infección de la vía urinaria, localización no especificada, SAI (trastorno), infección de la vía urinaria, localización no especificada, SAI, infección de las vías urinarias, infección urinaria (trastorno), infección urinaria, SAI (trastorno), infección urinaria, SAI, infección urinaria, Infecciones del tracto urinario, Infección del tracto urinario, Infecciones Urinarias
Japanese 尿路感染, 尿路感染ＮＯＳ, 尿路感染、部位不明, ﾆｮｳﾛｶﾝｾﾝ, ﾆｮｳﾛｶﾝｾﾝNOS, ﾆｮｳﾛｶﾝｾﾝﾌﾞｲﾌﾒｲ
Swedish Urinvägsinfektioner
Czech močové cesty - infekce, močové ústrojí - infekce, Infekce močových cest, blíže neurčené části, Infekční onemocnění močových cest, Infekce močových cest, Močová infekce, Infekce močových cest NOS
Finnish Virtsatieinfektiot
Russian MOCHEVYKH PUTEI INFEKTSII, МОЧЕВЫХ ПУТЕЙ ИНФЕКЦИИ
Korean 부위가 명시되지 않은 요로 감염
Croatian URINARNE INFEKCIJE
Polish Zakażenie dróg moczowych
Hungarian Fertőzés, húgyúti, Húgyúti fertőzések, húgyúti fertőzés, Húgyúti fertőzés, húgyúti fertőzés k.m.n., húgyúti fertőzés, hely nem meghatározott, UTI
Sources
Derived from the NIH UMLS (Unified Medical Language System)


Acute cystitis (C0149523)

Concepts Disease or Syndrome (T047)
ICD9 595.0
ICD10 N30.0
SnomedCT 197833009, 68226007, 155883005, 266628008
English CYSTITIS, ACUTE, acute cystitis (diagnosis), acute cystitis, Cystitis acute, Cystitis acute NOS, Cystitis;acute, cystitis acute, Acute cystitis, Acute cystitis (disorder), cystitis; acute, acute; cystitis, Acute Cystitis
Dutch cystitis acuut, cystitis acuut NAO, acute cystitis, acuut; cystitis, cystitis; acuut, Acute cystitis
French Cystite aiguë, Cystite aiguë SAI
German akute Zystitis, Zystitis akut NNB, Akute Zystitis
Italian Cistite acuta, Cistite acuta NAS
Portuguese Cistite aguda, Cistite aguda NE
Spanish Cistitis aguda, Cistitis aguda NEOM, Acute cystitis, cistitis aguda (trastorno), cistitis aguda
Japanese 急性膀胱炎ＮＯＳ, 急性膀胱炎, ｷｭｳｾｲﾎﾞｳｺｳｴﾝ, ｷｭｳｾｲﾎﾞｳｺｳｴﾝNOS
Czech Akutní cystitida NOS, Akutní cystitida
Korean 급성 방광염
Hungarian Cystitis, acut k.m.n., cystitis acuta, Cystitis, acut
Sources
Derived from the NIH UMLS (Unified Medical Language System)


Infective cystitis (C0600041)

Definition (NCI) A disorder characterized by an infectious process involving the bladder.
Definition (NCI) An infectious process affecting the urinary bladder.
Concepts Disease or Syndrome (T047)
SnomedCT 236620008
English BLADDER INFECTION, INFECTION BLADDER, Bladder Infections, Infections, Bladder, Infective cystitis, Bladder infection, Bladder infection NOS, Infection bladder, Infectious Cystitis, Infection;bladder, infection of bladder, bladder infections, Infection of bladder, Infective cystitis (disorder), bladder; infection, infection; bladder, bladder infection
Dutch blaasinfectie NAO, infectie blaas, blaasinfectie, blaas; infectie, infectie; blaas
French Infection de la vessie, Infection de la vessie SAI, INFECTION VESICALE
German Blaseninfektion, Blaseninfektion NNB, Infektion der Blase, BLASENINFEKTION
Italian Infezione vescicale, Infezione vescicale NAS, Infezione della vescica
Portuguese Infecção da bexiga, Infecção da bexiga NE, INFECCAO VESICAL
Spanish Infección de vejiga, Infección vesical, Infección vesical NEOM, INFECCION VEJIGA URINARIA, cistitis infecciosa (trastorno), cistitis infecciosa, infección de la vejiga
Japanese 膀胱感染, 膀胱感染ＮＯＳ, ﾎﾞｳｺｳｶﾝｾﾝ, ﾎﾞｳｺｳｶﾝｾﾝNOS
Czech Infekce močového měchýře, Infekce močového měchýře NOS
Hungarian húgyhólyagfertőzés, húgyhólyagfertőzés k.m.n., Fertőzés húgyhólyag
Sources
Derived from the NIH UMLS (Unified Medical Language System)


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