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Urinary Tract InfectionAka: UTI, Bladder Infection, Acute Cystitis

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  1. See Also
    1. UTI in Pregnancy
    2. UTI in children
  2. Causes
    1. Normal Host
      1. Escherichia coli (80%)
      2. Staphylococcus saprophyticus (10-15% of young women)
        1. More aggressive and recurrent infections
        2. Associated with Pyelonephritis
    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. Associated 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. Factors suggestive of complicated UTI
    1. Advanced age
    2. Chronic renal disease
    3. Diabetes Mellitus
    4. Immunodeficiency
    5. Pregnancy
    6. Recent Urinary Tract Instrumentation
    7. Urologic abnormalities
  5. 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)
  6. 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
    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
  7. 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
    2. Urinalysis
      1. Urine Leukocyte Esterase
      2. Urine Nitrite
      3. Urine White Blood Cells on microscopy
    3. Urine Culture
      1. Positive for >100k organisms
      2. Women with Dysuria have <100k organisms in 30% cases
  8. 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
        1. Uncomplicated treatment: 3 days (except noted)
          1. Nitrofurantoin and Macrobid course is 7 days
        2. Complicated treatment: 10-14 day course
      2. Antibiotic Resistance increasing
        1. Trimethoprim Sulfamethoxazole (Septra): 18%
        2. Ampicillin: 38%
        3. Nitrofurantoin resistance low (1-2%)
        4. Fluoroquinolone resistance low (2.5%)
          1. Avoid as first line agents if possible
          2. Consider in areas of high Septra resistance areas
      3. Cure may occur despite resistance to antibiotic used
      4. Risks for resistance
        1. Trimethoprim Sulfamethoxazole within last 3 months
        2. Diabetes Mellitus
        3. Recent hospitalization
        4. Resistance rates in community >20%
    3. Acute Uncomplicated UTI
      1. Bactrim DS 1 po bid for 3 days
      2. Also see Nitrofurantoin, Macrobid, Fosfomycin below
    4. Acute Uncomplicated UTI with risks for resistance
      1. Nitrofurantoin 100 mg PO qid for 5 days
      2. Macrobid 100 mg PO bid for 5 days
        1. Five days is sufficient course (previously used for 7 days)
        2. Gupta (2007) Arch Intern Med 167(20):2207
      3. Fosfomycin (Monurol) 3 grams for one dose
      4. Also see Fluoroquinolones below
    5. More severe disease or resistant UTI organisms
      1. 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
      2. Norfloxacin 400 mg PO bid for 3 days
      3. Ofloxacin 200 mg PO bid for 3 days
      4. Gatifloxacin (Tequin) 400 mg for one dose
      5. Gatifloxacin (Tequin) 200 mg twice daily for 3 days
    6. Antibiotics for UTI in Pregnancy
      1. See Urinary Tract Infection in pregnancy
    7. Other antibiotics used in urinary tract infection
      1. Cephalexin (Keflex) 250-500 mg PO qid
      2. Augmentin 875 mg PO bid
    8. Sexually active young patients
      1. Avoid Nitrofurantoin (Macrobid)
        1. Staphylococcus saprophyticus resistance
      2. Consider Chlamydia sceening
      3. Consider other Sexually Transmitted Disease Testing
  9. Management: Recurrent episodes
    1. See Recurrent Urinary Tract Infection
  10. 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
      2. Nicolle (2005) Clin Infect Dis 40:643
  11. References
    1. Ebell (2006) Am Fam Physician 73:293
    2. Gupta (1999) JAMA 281:736
    3. Hooton (1997) Infect Dis Clin North Am 11:551

Urinary tract infection (C0042029)

Definition (MSH)Inflammatory responses of the epithelium of the URINARY TRACT to microbial invasions. They are often bacterial infections with associated BACTERIURIA and PYURIA.
Definition (CSP)infections affecting stuctures participating in the secretion and elimination of urine: the kidneys, ureters, urinary bladder and urethra.
ConceptsDisease or Syndrome (T047)
ICD9599.0, V13.02
EnglishInfection of urinary tract, INFECTION URINARY TRACT, PERSONAL HISTORY UTI, URINARY TRACT INFECT, Urinary tract infection, Urinary tract infection; site not specified, Urinary Tract Infections, Urinary tract infectious disease, uti
Spanishenfermedad infecciosa de las vías urinarias, enfermedad infecciosa de las vias urinarias, infección de las vías urinarias, infección urinaria, infeccion de las vias urinarias, infeccion urinaria
CreditsDerived from the NIH UMLS (Unified Medical Language System)


Acute cystitis (C0149523)

ConceptsDisease or Syndrome (T047)
ICD9595.0
EnglishAcute Cystitis
Spanishcistitis aguda
CreditsDerived from the NIH UMLS (Unified Medical Language System)


Infective cystitis (C0600041)

ConceptsDisease or Syndrome (T047)
EnglishBLADDER INFECTION, INFECTION BLADDER, Infection of bladder, Infective cystitis
Spanishcistitis infecciosa, infección de la vejiga, infeccion de la vejiga
CreditsDerived from the NIH UMLS (Unified Medical Language System)



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