II. Causes
- Normal Host
- Escherichia coli (80-86%)
- Staphylococcus saprophyticus (10-15% of young women, 4% overall)
- More aggressive and recurrent infections
- Associated with Pyelonephritis
- Klebsiella (3%)
- Proteus (3%)
-
Nephrolithiasis associated infection
- Proteus (urease positive)
- Klebsiella
- Sexually Transmitted Diseases
III. Risk factors: Complicated Cystitis
- Male gender
- Pregnancy
- Hospital acquired Urinary Tract Infection
- Prolonged urinary tract symptoms (>1 week)
- Poorly controlled Diabetes Mellitus
- Immunocompromised
- Underlying urologic disorder
- Vesicoureteral reflux
- Recurrent complicated Urinary Tract Infections
- Catheter associated Urinary Tract Infection
- Neurogenic Bladder dysfunction
- Polycystic Kidney Disease
- Urologic instrumentation or stenting
- Status renal transplant
- Urinary Tract Obstruction (e.g. Nephrolithiasis)
- Men with Prostatitis or BPH
IV. Symptoms
- Most suggestive of Urinary Tract Infection
- Dysuria (Likelihood Ratio 2.0)
- If absent, Likelihood Ratio 0.5
- Urinary Frequency (Likelihood Ratio 1.8)
- Hematuria (Likelihood Ratio 1.5)
- Occurs in 30% of cases
- Dysuria (Likelihood Ratio 2.0)
- Other symptoms with Urinary Tract Infection
- Urinary Urgency
- Suprapubic Pain (especially after voiding)
V. Differential Diagnosis
-
Dysuria
- See Dysuria
- See Dysuria in Children
- See Dysuria in Men
- See Dysuria in Women
-
Urethritis
- Pain at onset of urination
-
Vaginitis
- External Dysuria
- Vaginal irritation or discharge
-
Chlamydia trachomatis
- Long, insidious onset
- Sexually active
-
Acute Pyelonephritis
- Fever, flank pain, and Nausea or Vomiting
- Risk factors for cystitis with occult Pyelonephritis
- Women (30% have subclinical Pyelonephritis)
- Pregnancy
- Diabetes Mellitus
- Immunocompromised patients
- Urinary Tract Infection under age 12 years
- Genitourinary comorbid condition
VI. Labs
-
Urinalysis
- Urine Leukocyte Esterase (high Test Sensitivity but low Test Specificity)
- Urine Nitrite (high Test Specificity, but low Test Sensitivity)
- Urine White Blood Cells on microscopy
-
Urine Culture
- Recommended in complicated UTI or suspected Pyelonephritis
- Positive for >100k organisms
- Women with Dysuria have <100k organisms in 30% cases
VII. Diagnosis: Factors suggestive of complicated UTI
- Extremes of age (preadolescent, or post-Menopause)
- Chronic renal disease
- Diabetes Mellitus
- Immunodeficiency
- Pregnancy
- Recent Urinary Tract Instrumentation
- Ureteral Stents
- Indwelling catheters
- Urologic abnormalities
VIII. Diagnosis: Prediction Rule
- Criteria
- New onset frequency and Dysuria
- Absent Vaginal Discharge and irritation
- Efficacy
- Pretest probability of UTI based on symptoms: 90%
- Probablity of UTI with negative Urinalysis: 23%
- Positive Predictive Value: 90%
- Interpretation
- May be treated without Urinalysis and Urine Culture
- Editorial note: I do not recommended this (other Dysuria causes, Antibiotic Overuse)
- Alternative: Even dipstick testing alone is reasonably accurate, priced and fast
- Reference
IX. Diagnosis: Findings suggestive of upper Urinary Tract Infection (Pyelonephritis)
- See Pyelonephritis
- Fever, chills
- Flank pain
- Vomiting
- Pregnancy (second and third trimester are higher risk)
- Underlying urinary tract disorder
- History of Ureteral Stenting or other instrumentation
- Male patients
- Insulin Dependent Diabetes Mellitus
- HIV Infection
- Immunosuppressants (Chronic Corticosteroid use, status-post transplant)
- Extremes of age (very young or very old)
- Underwhelming presentations of upper tract disease
X. Precautions
- Consider Sexually Transmitted Infection in Vaginitis or male Dysuria
- Consider Nephrolithiasis with Urinary Tract Infection (emergency) when flank pain is severe
- Empiric antibiotic regimens should be based on local resistance rates
- Urine Culture is not needed needed in occasional, uncomplicated Urinary Tract Infection
- Assume upper tract disease in findings listed above
- Adjust management strategy to treat upper tract (e.g. avoid Macrobid or Nitrofurantoin)
XI. Management
-
General measures in women
- Women should clean perineum wiping front to back
- Women should empty Bladder before, after intercourse
- Avoid Contraceptive Diaphragm
- Antibiotics
- Course: Anticipate symptom relief within 36 hours of starting antibiotics
- Antibiotic duration
- Uncomplicated treatment: 3 days (except noted)
- Nitrofurantoin and Macrobid course is 5 days (was 7 days)
- Complicated treatment: 10-14 day course
- Uncomplicated treatment: 3 days (except noted)
- Antibiotic Resistance increasing
- Trimethoprim Sulfamethoxazole (Septra): 18%
- Beta Lactams: 20%
- Ampicillin: 38%
- Nitrofurantoin resistance low (1-2%)
- Fluoroquinolone resistance low (2.5%)
- Avoid as first line agents if possible
- Consider in areas of high Septra resistance areas
- Cure may occur despite resistance to antibiotic used
- Risks for resistance
- Trimethoprim Sulfamethoxazole within last 3-6 months
- Diabetes Mellitus
- Recent hospitalization
- Travel outside United States
- Resistance rates in community >20%
- Acute Uncomplicated UTI: First-Line agents
- Note that Ciprofloxacin has been demoted from first-line agent due to adverse effects (see below)
- Bactrim DS one orally twice daily for 3 days
- Avoid if local resistance rate >20%
- Nitrofurantoin (Macrobid) one orally twice daily for 5 days
- Avoid if GFR <30 ml/min (risk of interstitial pulmonary fibrosis)
- Fosfomycin (Monurol) 3 grams for one dose
- Consider as a single dose in Emergency Department (e.g. patient non-compliant)
- More expensive and may be less effective (58% efficacy compared with 70% for Nitrofurantoin)
- Acute Uncomplicated UTI with risks for resistance (prior Bactrim use or international travel in last 6 months)
- Nitrofurantoin
- Avoid if GFR <30 ml/min (risk of interstitial pulmonary fibrosis)
- Nitrofurantoin 100 mg orally four times daily for 5 days
- Macrobid 100 mg orally twice daily for 5 days
- Five days is sufficient course (previously used for 7 days)
- Gupta (2007) Arch Intern Med 167(20):2207-12 [PubMed]
- Fosfomycin (Monurol) 3 grams for one dose
- Also see Fluoroquinolones below
- Nitrofurantoin
- More severe disease or resistant UTI organisms: Fluoroquinolones
- Precautions regarding Fluoroquinolones
- Risk of Tendinopathy (and Achilles Tendon Rupture) and Peripheral Neuropathy
- Avoid if local resistance rate >10%
- Renal dose adjustment required if GFR reduced
- Although 3 day courses are listed, complicated UTI is typically treated for 7-14 days (up to 6 weeks in men)
- Ciprofloxacin 250 mg PO bid for 3 days
- In healthy older women, 3 days equivalent to 7 days
- Vogel (2004) CMAJ 170:469-73 [PubMed]
- Norfloxacin 400 mg PO bid for 3 days
- Ofloxacin 200 mg PO bid for 3 days
- Avoid Moxifloxacin and gemifloxacin (poor penetration into urine)
- Precautions regarding Fluoroquinolones
- Antibiotics for UTI in Pregnancy
- Other antibiotics used in Urinary Tract Infection
- Precautions
- Beta lactams have lower efficacy in UTI
- Cephalexin (Keflex) 250-500 mg PO qid
- Augmentin 875 mg orally twice daily
- Precautions
- Sexually active young patients
- Avoid Nitrofurantoin (Macrobid)
- Staphylococcus saprophyticus resistance
- Consider Chlamydia sceening
- Consider other Sexually Transmitted Disease Testing
- Avoid Nitrofurantoin (Macrobid)
XII. Management: Special Circumstances
XIII. Management: Asymptomatic Bacteriuria
XIV. References
- Colgan (2011) Am Fam Physician 84(7): 771-6 [PubMed]
- Ebell (2006) Am Fam Physician 73:293-6 [PubMed]
- Gupta (1999) JAMA 281:736-8 [PubMed]
- Gupta (2012) Ann Intern Med 156(5): ITC3-1 [PubMed]
- Hooton (1997) Infect Dis Clin North Am 11:551-81 [PubMed]
- Michels (2015) Am Fam Physician 92(9): 778-86 [PubMed]
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Definition (MSHCZE) | Zánětlivé reakce epitelu močového ústrojí na mikrobiální invazi. Časté jsou bakteriální infekce spojené s BAKTERIURIÍ a PYURIÍ. |
Definition (MEDLINEPLUS) |
The urinary system is the body's drainage system for removing wastes and extra water. It includes two kidneys, two ureters, a bladder, and a urethra. Urinary tract infections (UTIs) are the second most common type of infection in the body. You may have a UTI if you notice
People of any age or sex can get UTIs. But about four times as many women get UTIs as men. You're also at higher risk if you have diabetes, need a tube to drain your bladder, or have a spinal cord injury. If you think you have a UTI it is important to see your doctor. Your doctor can tell if you have a UTI with a urine test. Treatment is with antibiotics. NIH: National Institute of Diabetes and Digestive and Kidney Diseases |
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_CTCAE) | A disorder characterized by an infectious process involving the urinary tract, most commonly the bladder and the urethra. |
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 | 155897002, 197930008, 266635000, 266634001, 155896006, 197924008, 274110008, 68566005 |
LNC | LA6437-3 |
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, UTI, Urinary tract infections, 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, Infection urinary tract, Urinary tract infection NOS, Urinary infection, Urin tract infection NOS, Urinary Tract Infections [Disease/Finding], urinary tract infection (UTI), utis, urinary tract infections, urinary infection, Urinary Tract Infection, Urinary tract infection, site not specified NOS (disorder), Infection - urinary NOS, Urinary tract infection (& [NOS]) (disorder), Urinary tract infection (& [NOS]), Urinary infection NOS (disorder), INFECTION, URINARY TRACT, Urinary Tract Infectious Disease, TRACT, INFECTION OF URINARY, 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, Urinary tract infection, NOS, Urinary tract infectious disease, 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, INFECCION VIAS URINARIAS, infección urinaria, SAI, infección urinaria, SAI (trastorno), infección de la vía urinaria, localización no especificada, SAI, infección de la vía urinaria, localización no especificada, SAI (trastorno), enfermedad infecciosa de las vías urinarias, infección de las vías urinarias, infección urinaria (trastorno), 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, ニョウロカンセンブイフメイ |
Swedish | Urinvägsinfektioner |
Czech | močové cesty - infekce, Infekce močových cest, blíže neurčené části, Infekční onemocnění močových cest, Infekce močových cest, Močová infekce, Infekce močových cest NOS, infekce močového ústrojí, močové ústrojí - infekce, močové infekce |
Finnish | Virtsatieinfektiot |
Russian | MOCHEVYKH PUTEI INFEKTSII, МОЧЕВЫХ ПУТЕЙ ИНФЕКЦИИ |
Korean | 부위가 명시되지 않은 요로 감염 |
Croatian | URINARNE INFEKCIJE |
Hungarian | Fertőzés, húgyúti, Húgyúti fertőzések, húgyúti fertőzés, Húgyúti fertőzés, húgyúti fertőzés k.m.n., húgyúti fertőzés, hely nem meghatározott, UTI |
Polish | Zakażenie układu moczowego, Infekcja dróg moczowych, Zakażenia dróg moczowych, Infekcje dróg moczowych |
Norwegian | Urinveisinfeksjoner |
Ontology: Acute cystitis (C0149523)
Definition (NCI) | An acute infection of the bladder. It is usually caused by bacteria. Signs and symptoms include increased frequency of urination, pain or burning during urination, fever, cloudy or bloody urine, and suprapubic pain. |
Concepts | Disease or Syndrome (T047) |
ICD9 | 595.0 |
ICD10 | N30.0 |
SnomedCT | 197833009, 155883005, 266628008, 68226007 |
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, cistitis aguda (trastorno), cistitis aguda |
Japanese | 急性膀胱炎NOS, 急性膀胱炎, キュウセイボウコウエン, キュウセイボウコウエンNOS |
English | 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 |
Czech | Akutní cystitida NOS, Akutní cystitida |
Korean | 급성 방광염 |
Hungarian | Cystitis, acut k.m.n., cystitis acuta, Cystitis, acut |
Ontology: Infective cystitis (C0600041)
Definition (NCI) | An infectious process affecting the urinary bladder. |
Definition (NCI_CTCAE) | A disorder characterized by an infectious process involving the bladder. |
Concepts | Disease or Syndrome (T047) |
SnomedCT | 236620008 |
English | BLADDER INFECTION, Infective cystitis, Bladder infection, Bladder infection NOS, Infection bladder, Infectious Cystitis, Infection;bladder, bladder infection, infection of bladder, bladder infections, Bladder Infections, Infections, Bladder, Infective cystitis (diagnosis), cystitis infective, Infection of bladder, Infective cystitis (disorder), bladder; infection, infection; bladder |
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, ボウコウカンセン, ボウコウカンセンNOS |
Czech | Infekce močového měchýře, Infekce močového měchýře NOS |
Hungarian | húgyhólyagfertőzés, húgyhólyagfertőzés k.m.n., Fertőzés húgyhólyag |