Urinary Tract Infection

1. Urinary Tract Infection Michele Ritter, M.D. Argy Resident – Feb. 2007

2. Urinary Tract Infection • Upper urinary tract Infections: • Pyelonephritis • Lower urinary tract infections • Cystitis(“traditional” UTI) • Urethritis (often sexually-transmitted) • Prostatitis

3. Symptoms of Urinary Tract Infection • Dysuria • Increased frequency • Hematuria • Fever • Nausea/Vomiting (pyelonephritis) • Flank pain (pyelonephritis)

4. Findings on Exam in UTI • Physical Exam: • CVA tenderness (pyelonephritis) • Urethral discharge (urethritis) • Tender prostate on DRE (prostatitis) • Labs: Urinalysis • + leukocyte esterase • + nitrites • More likely gram-negative rods • + WBCs • + RBCs

5. Culture in UTI • Positive Urine Culture = >105 CFU/mL • Most common pathogen for cystitis, prostatitis, pyelonephritis: • Escherichia coli • Staphylococcus saprophyticus • Proteus mirabilis • Klebsiella • Enterococcus • Most common pathogen for urethritis • Chlamydia trachomatis • Neisseria Gonorrhea

6. Lower Urinary Tract Infection - Cystitis • Uncomplicated (Simple) cystitis • In healthy woman, with no signs of systemic disease • Complicated cystitis • In men, or woman with comorbid medical problems. • Recurrent cystitis

7. Uncomplicated (simple) Cystitis • Definition • Healthy adult woman (over age 12) • Non-pregnant • No fever, nausea, vomiting, flank pain • Diagnosis • Dipstick urinalysis (no culture or lab tests needed) • Treatment • Trimethroprim/Sulfamethoxazole for 3 days • May use fluoroquinolone (ciprofoxacin or levofloxacin) in patient with sulfa allergy, areas with high rates of bactrim-resistance • Risk factors: • Sexual intercourse • May recommend post-coital voiding or prophylactic antibiotic use.

8. Complicated Cystitis • Definition • Females with comorbid medical conditions • All male patients • Indwelling foley catheters • Urosepsis/hospitalization • Diagnosis • Urinalysis, Urine culture • Further labs, if appropriate. • Treatment • Fluoroquinolone (or other broad spectrum antibiotic) • 7-14 days of treatment (depending on severity) • May treat even longer (2-4 weeks) in males with UTI

9. Special cases of Complicated cystitis • Indwelling foley catheter • Try to get rid of foley if possible! • Only treat patient when symptomatic (fever, dysuria) • Leukocytes on urinalysis • Patient’s with indwelling catheters are frequently colonized with great deal of bacteria. • Should change foley before obtaining culture, if possible • Candiduria • Frequently occurs in patients with indwelling foley. • If grows in urine, try to get rid of foley! • Treat only if symptomatic. • If need to treat, give fluconazole (amphotericin if resistance)

10. Recurrent Cystitis • Want to make sure urine culture and sensitivity obtained. • May consider urologic work-up to evaluate for anatomical abnormality. • Treat for 7-14 days.

11. Pyelonephritis • Infection of the kidney • Associated with constitutional symptoms – fever, nausea, vomiting, headache • Diagnosis: • Urinalysis, urine culture, CBC, Chemistry • Treatment: • 2-weeks of Trimethroprim/sulfamethoxazole or fluoroquinolone • Hospitalization and IV antibiotics if patient unable to take po. • Complications: • Perinephric/Renal abscess: • Suspect in patient who is not improving on antibiotic therapy. • Diagnosis: CT with contrast, renal ultrasound • May need surgical drainage. • Nephrolithiasis with UTI • Suspect in patient with severe flank pain • Need urology consult for treatment of kidney stone

12. Prostatitis • Symptoms: • Pain in the perineum, lower abdomen, testicles, penis, and with ejaculation, bladder irritation, bladder outlet obstruction, and sometimes blood in the semen • Diagnosis: • Typical clinical history (fevers, chills, dysuria, malaise, myalgias, pelvic/perineal pain, cloudy urine) • The finding of an edematous and tender prostate on physical examination • Will have an increased PSA • Urinalysis, urine culture • Treatment: • Trimethoprim/sulfamethoxazole, fluroquinolone or other broad spectrum antibiotic • 4-6 weeks of treatment • Risk Factors: • Trauma • Sexual abstinence • Dehydration

13. Urethritis • Chlamydia trachomatis • Frequently asymptomatic in females, but can present with dysuria, discharge or pelvic inflammatory disease. • Send UA, Urine culture (if pyuria seen, but no bacteria, suspect Chlamydia) • Pelvic exam – send discharge from cervical or urethral os for chlamydia PCR • Chlamydia screening is now recommended for all females ≤ 25 years • Treatment: • Azithromycin – 1 g po x 1 • Doxycycline – 100 mg po BID x 7 days • Neisseria gonorrhoeae • May present with dysuria, discharge, PID • Send UA, urine culture • Pelvic exam – send discharge samples for gram stain, culture, PCR • Treatment: • Ceftriaxone – 125 mg IM x 1 • Cipro – 500 mg po x 1 • Levofloxacin – 250 mg po x 1 • Ofloxacin – 400 mg po x 1 • Spectinomycin – 2 g IM x 1 • You should always also treat for chlamydia when treating for gonnorhea!

14. Question #1 • An 18-year old woman presents with urinary frequency, dysuria, and low-grade fever. Urinalysis shows pyuria and bacilli. She has never had similar symptoms or treatment for urinary tract infection.

15. Question # 1 • What category of UTI does this patient have? • Does this patient require further testing? • Would you treat this patient, and if so, with what and how long?

16. Question # 2 • An 18-year old woman present with her third episode of urinary frequency, dysuria, and pyuria in the past 4 months.

17. Question # 2 • What further questions do you have for this patient? • What type of UTI does this patient have? • What testing might you perform in this patient? • How would you treat her, and for how long?

18. Question #3 • A 24-year old woman presents with fever, chills, nausea, vomiting, flank pain and tenderness. Her temperature is 40°C, pulse rate is 120/min., and blood pressure is 100/60 mm Hg.

19. Question # 3 • What further studies do you want in this patient? • How would you treat this patient? • What might you do if she does not improve after 3-4 days?

20. Question # 4 • A 78-year old female presents with an indwelling foley catheter and pyuria.

21. Question # 4 • What would you do for this patient at this time? • How might your work-up/management change if she was having fevers and confusion?

22. Question # 5 • 58-year old man presents with his first episode of urinary frequency and dysuria. Urinalysis shows pyuria and bacilli.

23. Question # 5 • What type of UTI does this patient likely have? • How would you treat this man, and for how long? • What activities would put this patient at risk for UTI?

24. Question # 6 • A 28-year old male had a sexual encounter with a prostitute while on a business trip in Seattle 1 week ago. After returning home, he noted a burning sensation on urination and a yellow discharge in his underwear. Microscopic examination of the discharge reveals 4+ leukocyte esterase, and the following gram stain.

25. Question # 6

26. Question # 6 • Which of the following is the best course of action for this patient? • Give the patient a prescription for doxycycline, 100 mg po BID for 7 days • Give the patient two prescriptions for ofloxacin 300 mg po QDay for 7 days, one for him, and one for his wife. • Administer ceftriaxone – 125 mg IV x 1 and Azithromycin – 1 g po x 1, draw blood for a VDRL and HIV – antibody arrange for his wife to be examined and treated. • Administer a single dose of Ceftriaxone – 125 mg IV x 1, and ciprofloxacin – 500 mg po x 1 draw blood for a VDRL and HIV-antibody, and arrange for his wife to be examined and treated. • Administer a single dose of cefixime – 400 mg, draw blood for a VDRL and arrange for his wife to be examined and treated.

27. Final thoughts! • Antibiotic choice and duration are determined by classification of UTI. • Biggest bugs for UTI are E. Coli, Staph. Saprophyticus, Proteus mirabilis, Enterococci and gram-negatives • Don’t use moxifloxacin for UTI! • Chlamydia screening is now recommended for all women 25 years and under since infection is frequently asymptomatic, and risk for PID/infertility is high!