For undergrads

1. AMBER Z JAFFERI
EMERGENCY DEPARTMENT SIH
Urinary Tract Infection

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?
a) Give the patient a prescription for doxycycline, 100 mg po BID for 7
days
b) Give the patient two prescriptions for ofloxacin 300 mg po QDay for
7 days, one for him, and one for his wife.
c) 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.
d) 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.
e) 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!