Published - Fri, 22 Jul 2022

URINARY TRACT INFECTIONS (UTIs)

URINARY TRACT INFECTIONS (UTIs)

Urinary tract infections (UTIs) are commonly evaluated in the emergency department (ED). Most UTIs are caused by pathogens that normally inhabit the perineum and gastrointestinal tract.

80-90% to one hundred percent of UTIs are caused by Escherichia coli.

Klebsiella, Proteus, Enterobacter, and Pseudomonas species account for 10% to 20% of cases.

Group D Streptococcus, Chlamydia, and Staphylococcus are responsible in fewer than 5% of cases.



Predisposing factors:

Women are affected more often than men because the shorter female urethra facilitates bacterial access to the bladder.

a) Sexual intercourse and the use of nonoxynol-9–containing spermicides predispose to the development of UTIs.

b) A significant frequency of asymptomatic bacteriuria is linked to pregnancy.

c) Postmenopausal state

d) Immunosuppression


Men

a) Predisposing conditions (e.g., anatomic abnormalities, tumors, calculi, prostatitis, and enlarged prostate) are found in up to 80% of men with UTIs.

b) Many male UTI cases are caused by catheterization.

c) Uncircumcised men (and women who have intercourse with uncircumcised men) are more prone to UTIs.

d) Immunosuppression



Clinical features:

Symptoms: Presenting symptoms may include urinary urgency, frequency, nocturia, dysuria, a sensation of incomplete voiding, and suprapubic pain. Patients with upper tract involvement may also have fever, chills, nausea, and vomiting.

Physical examination findings: Flank pain, mild suprapubic midline tenderness, and costovertebral angle tenderness may be associated with pyelonephritis and cystitis.



Differential diagnoses:

—Vaginitis resulting from Candida albicans, Trichomonas vaginalis, or Gardnerella infection must be considered.

—When males appear with urethral discharge, urethritis is a crucial factor to take into account. Neisseria gonorrhoeae and Chlamydia trachomatis are the most prevalent pathogens.

Prostatitis: The most common infecting organisms are E. coli (80% of cases), Pseudomonas, Klebsiella, Proteus, and Enterococcus. 



Evaluation:

1).Urinalysis should be performed on a midstream clean-catch specimen. Patients with certain clinical conditions (e.g., vaginal discharge, vaginal bleeding, obesity) may need to be catheterized to obtain a urine specimen.

a) Microscopic analysis: 

Hematuria could be an indication of upper or lower tract involvement.

Bacteriuria: More than 10 to 15 organisms per high-power field on a centrifuged specimen is suggestive of UTI. Finding any bacteria on an uncentrifuged specimen correlates with a positive urine culture.

Pyuria is defined by the presence of more than 10 white blood cells (WBCs) per high-power field.


b) Dipstick analysis:

Leukocyte esterase test: The leukocyte esterase test is a reliable screen for pyuria, although false-negative results may occur with low-level pyuria.

The presence of nitrites is a sign of gram-negative bacterial infection.


2). Urine cultures:

a) Indications: Urine cultures are not routinely ordered on uncomplicated infections but may be indicated in some patients. Examples include immunosuppressed patients, suspected pyelonephritis, indwelling catheters, patients who fail to respond to therapy, patients requiring hospitalization, or a history of drug-resistant infections.

b) Interpretation: A positive culture is one where 105 colonies/mL of urine are growing.


3). Complete blood count (CBC): The CBC may reveal leukocytosis in patients with suspected pyelonephritis. The leukocyte count is not generally elevated or indicated in patients with only cystitis.



Therapy:

1). Cystitis:

—Uncomplicated cases: In patients without constitutional symptoms or complicating medical conditions and a short duration of symptoms, uncomplicated cystitis can be treated with a 5-day course of nitrofurantoin, or a 3-day course of oral trimethoprim–sulfamethoxazole.

—Complicated cases: In patients with complicating medical conditions, a longer duration of symptoms, or a relapse of infection, 7 to 10 days of therapy is required.

—Pregnant patients: Uncomplicated cystitis and asymptomatic bacteriuria in pregnant women can be treated with oral amoxicillin, nitrofurantoin, or cefpodoxime.


2). Pyelonephritis:

a) Outpatient treatment

Parenteral antibiotics should be given before discharge. Ceftriaxone (1–2 g) or gentamicin (1.0 mg/kg) with ampicillin (1–2 g).

—Oral antibiotics: A 10- to 14-day course of trimethoprim–sulfamethoxazole (160/800 mg, twice daily by mouth) or a fluoroquinolone (e.g., ciprofloxacin, 500 mg twice daily) is required. Nitrofurantoin shouldn't be used to treat pyelonephritis.

b)Inpatient management entails the intravenous administration of the Parenteral antibiotics [Ceftriaxone (1–2 g) or gentamicin (1.0 mg/kg) with ampicillin (1–2 g)], or aztreonam (0.5–2 g two to four times daily), imipenem (600 mg three to four times daily), or ciprofloxacin (200–400 mg intravenously twice daily).



Disposition:

Patients who need to be admitted to the hospital include:

—Those with clinical toxicity (e.g., fever, vomiting, ill-appearing)

—Those who are unable to take oral fluids or drugs..

—Patients with pyelonephritis who are very young, pregnant, or elderly


Discharge: Most patients are treated as outpatients. Before discharge, patients should be advised regarding the prevention of UTIs. There are several widely used strategies for preventing UTIs:

—Practicing postcoital voiding

—Urinating frequently and completely;

—Increasing fluid intake 

—Observing regional hygiene (including wiping from front to back)

Created by

Rigomo Team

Rigomo is a leading online education platform that offers a wide range of courses to help individuals enhance their skills and achieve their career goals. With our user-friendly interface and expert instructors, we strive to provide high-quality education to everyone, anytime and anywhere. Join us today and take the first step towards a brighter future.

Rigomo is an e-learning platform that was founded in 2019 by a team of dedicated professionals with a passion for revolutionizing the way people learn. The platform offers a range of online courses that cover various industries, including business, technology, healthcare, and more.

Rigomo's courses are designed to be interactive and engaging, with a focus on practical skills that learners can apply in their careers. The platform uses a combination of video lectures, quizzes, and hands-on projects to help learners master the subject matter.

Rigomo is committed to providing affordable and accessible education to people around the world. The platform offers a range of pricing options, including monthly and annual subscriptions, as well as pay-as-you-go options for individual courses.

Since its launch, Rigomo has received numerous accolades for its innovative approach to e-learning. The platform has helped thousands of learners across the globe acquire new skills and advance their careers.

As Rigomo continues to grow, the team remains committed to providing high-quality education that is accessible to all. The platform is constantly updating its courses and features to ensure that learners have access to the latest tools and technologies.

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