Outpatient / Infectious Disease

Urinary Tract Infection (UTI)

Last Updated: 3/5/2023

# *** Uncomplicated/Complicated Urinary Tract Infection

Intake:

-- Onset: *** ‍

-- Symptoms: *** frequency, urgency, dysuria, incontinence, nocturia, suprapubic tenderness, hematuria; if discharge, vaginitis, consider STI as well

-- Red Flags: *** prior MDRO UTI, fevers/chills, n/v, flank pain, male, c/f obstruction, immunocompromised, renal transplant, indwelling catheter - all make UTI “complicated”

-- Sexual Hx: *** pregnancy, recent partners, protection, hx of STI

-- Previous UTI: *** ‍

-- DDx: *** vaginitis, urethritis, PID, nephrolithiasis, interstitial cystitis, drug or radiation cystitis

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Plan:

-- Abx: ***

  • Uncomplicated - bactrim DS BID 3 days, nitrofurantoin 100mg BID 5 days (avoid in CKD), fosfomycin 3g once, augmentin 500mg BID 7 days, cefpodoxime 200mg BID 7 days
  • Complicated - bactrim DS 10 days, levoflox 750mg 7-10 days (if c/f pyelo)

-- Send pregnancy test if possibly pregnant

-- Send UA or UCx if elderly, complicated, treatment not working after 2-3 days, or recurrent within last 3 months

-- Consider sending UTI testing (chlamydia and gonorrhea)

-- Consider PPx with Bactrim or cephalexin if recurrence (>=2 episodes in 6 months or >=3 in a year); also topical estrogen if post-menopausal, methenamine hippurate with vitamin C

-- Refer: send to the ED/hospital if systemic symptoms concerning for pyelo or sepsis (UTIs are the most common infection leading to septic shock) inability to take PO meds, immunocompromised

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Patient Guidance and Information

Uncomplicated UTI Treatment

Based on your history and symptoms, you likely have a urinary tract infection (UTI).

You should take *** for ***. We will need to have a urine pregnancy test done beforehand.

Please let us know if your symptoms do not get better in the next 2-3 days, or if you develop fevers, nausea/vomiting, or abdominal/flank pain which can indicate a worsening UTI involving your kidneys.

In general, to avoid UTIs, avoid using douching products, be sure to drink plenty of fluids (2-3L per day), and urinate shortly after sexual activity.

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If You Remember Nothing Else

UTIs (specifically acute cystitis) are common and many can be treated just based on clinical story. Avoid nitrofurantoin if the patient may be pregnant. Common abx for ucomplicated UTIs include Bactrim DS BID 3 days, nitrofurantoin 100mg BID 5 days, cefpodoxime 200mg BID 7 days. If the UTI is complicated (prior MDRO UTI, fevers/chills, n/v, flank pain, male, c/f obstruction, immunocompromised, renal transplant, indwelling catheter) or there is concern for treatment failure after 2-3 days, they should be seen in clinic and have UA/UCx sent. If there is concern for pyelonephritis or sepsis, they should be sent to the ED.

Clinical Pearls

  • UTI is only when bacteria are in urinary tract and are causing inflammation leading to clinical symptoms, otherwise can represent colonization and no underlying infection
  • 40% of women will have a UTI sometime in their lives
  • Asymptomatic bacteriuria or pyuria should not be treated UNLESS pregnancy, recent renal transplant, planing to undergo urologic procedure
  • Criteria for treating without being seen in clinic - If patient has NOT been treated for a UTI within the last 6 weeks, has had symptoms less than a week in duration and is less than 75 years old, and patient is NOT pregnant or has other concerning symptoms
  • Cystitis is considered a “lower” UTI and generally felt to hold lower risk in those without anatomic or function concerns; “upper” UTI more likely to be complicated and involve renal parenchyma
  • Pyruria is if >=5-10 WBC on UA microscopy - this is the most important part of diagnosis
  • If dipstick has both nitrite and LE positive, sensitivity is 68-88%; enteobacterales (E. Coli) convert nitrate to nitrite; however note that dipstick not always helpful
  • Seeing bacteria on UA is pretty much useless since theres almost always some contamination from clean catch
  • Common UTI bugs include E. Coli (80%), klebsiella (3%), proteus, staph saprophyticus (10%)
  • If you see staph aureus in urine, think bacteremia
  • Most common risk is intercourse in women 15-30 years old; more common risks in older women include prolapse, loss on normal flora
  • Pyelonephritis is a complicated UTI - can further be complicated by abscess
  • Nitrofurantoin and fosfomycin do not have soft tissue penetration and are poor choices for pyelo
  • Don’t use fluoroquinolones in the outpatient setting unless you have to, also save the one time dose of fosfomycin for those who are resistant and for stewardship
  • Risk of developing vulvovaginits after being treated with abx for UTI
  • If neutropenic, possibly will not see pyuria on the dip
  • Will eventually have same microbiota as sexual partner after 1 year
  • If you see hematuria, consider adenovirus, CMS, and BK virus as causes of hemorrhagic cystitis
  • If see candida on urine culture its usually a contaminant
  • Alkaline urine pH >8 can suggest proteus, klebsiella, and staph saprophyticus which can all cause struvite crystals
  • Pyelonephritis is being called more often now on CTAP scans
  • Interstitial cystitis or “painful bladder syndrome” is chronic cystitis-like pain without etiology, pain often relieved with voiding and worsened by bladder filling - generally clinical diagnosis and associated with anxiety, depression, fibromyalgia - can treat with bladder training, therapy, PT, amitriptyline
  • Symptoms of UTI are more commonly atypical (e.g., back pain, pelvic pain, constipation, urinary incontinence, and altered mental status).
  • All catheters will eventually become colonized with bacteria so a positive urine dip means very little.

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