Uncomplicated Urinary Tract Infection

Young female presents with acute onset dysuria, urinary frequency/urgency. Pt recently became sexually active for the first time. Denies change in urine appearance/odor. Denies chills, rigors, marked increase in fatigue. Denies h/o confirmed multidrug resistant UTI. Afebrile with no suprapubic tenderness on exam; no costovertebral angle tenderness.

• Urine dipstick positive for leukocyte esterase, nitrites

• Obtain urine pregnancy test, urine culture

• Pregnancy test negative: Start nitrofurantoin 100 mg BID x5 days and adjust antibiotic therapy pending culture

Notes

• Symptom interpretation

  • Change in urine color/smell is not specific for UTI and should not prompt further workup in the absence of other symptoms

  • Women who self-diagnose UTI have a 85% positive culture rate; this is more accurate than dipstick testing

• Dipstick interpretation

  • Leukocyte esterase: 75% sensitivity, 98% specificity

  • Nitrites: 30% sensitivity, 90% specificity

• Cranberry products are not effective in relieving symptoms

• Pregnancy considerations

  • Antibiotics

    • Fosfomycin 3 g as a single dose is safe in all three trimesters, but may have decreased efficacy compared to other first-line agents (IDSA 2018)

    • Nitrofurantoin is safe in the 2nd and 3rd trimesters

    • TMP-SMX is contraindicated

  • Perform test of cure 1 week after starting therapy

Acute, Complicated Urinary Tract Infection

Elderly male with h/o indwelling Foley catheter and repeat UTIs presents with new onset urinary frequency/urgency in the setting of increased debility. Caretaker reports recent chills, rigors, flank pain. Fever, altered mental status, abdominal/suprapubic tenderness, costovertebral angle tenderness on exam.

• Labs

  • Obtain CBC, BMP, urine/blood cultures

  • Dipstick positive for leukocyte esterase, nitrites

  • Urinalysis positive for pyuria, bacteria

• Consider abdominal/pelvic CT with and without contrast in the following scenarios:

  • Patient meets sepsis criteria

  • Symptoms do not improve after 72 hours of antibiotic therapy

• Admit for inpatient management if the patient meet any of the following criteria:

  • Debility and/or marked change in overall health status

  • Fever >38.4

  • Pt requires IV antibiotic therapy, e.g.

    • Inability to maintain PO hydration and/or tolerate PO therapy

    • Treatment with IV agent indicated (see below)

• Antibiotic therapy

  • Meropenem 1 g IV q8 hours x 10 days for any of the following:

    • History of infection with multidrug-resistant organism

    • Long term care facility resident or recent hospitalization

    • Treatment with broad spectrum beta-lactam, TMP-SMX or fluoroquinolone within the past week

  • Otherwise start ceftriaxone 1 g IV daily x 10 days; transition to cefdinir (Omnicef) 300 mg BID and complete course once pt can tolerate PO intake

• Adjust antibiotic therapy pending culture sensitivities

Notes

• Complicated UTI includes infections extending beyond the bladder, e.g. pyelonephritis

• Clinical definition: One of the following must apply

  • Fever + s/sx systemic illness, e.g. new onset debility, chills/rigors

  • Pyuria + one of the following

    • Flank pain/CVA tenderness or imaging indicating pyelonephritis

    • Fever and/or sepsis

• Dipstick interpretation

  • Leukocyte esterase: 75% sensitivity, 98% specificity

  • Nitrites: 30% sensitivity, 90% specificity

• Microbiology/urine culture

  • Most commonly associated bacterial pathogens are nitrite producing and include E. coli, Klebsiella, and Proteus species

  • Positive if >100,000 bacterial colony forming units present

• Diagnostic reference: Urinalysis Evidence Based Summary