APPROACH TO URINARY
INFECTION IN PRIMARY CARE
ASSOC PROF HÜLYA AKAN,MD
DEPARTMENT OF FAMILY
MEDICINE
Objectives
• At the end of this lesson students should
be able to explain approach to
- Acute uncomplicated lower tract infection
in women
- Recurrent lower tract infection in women
- Acute upper tract infection (pyelonephritis)
in women
- UTIs in men
- UTI s in children
• The urinary tract is
comprised of the kidneys,
ureters, bladder, and
urethra
• A urinary tract infection
(UTI) is an infection
caused by pathogenic
organisms (for example,
bacteria, fungi, or
parasites) in any of the
structures that comprise
the urinary tract.
• Dysuria is the most prominent symptom
and accounts for 3% of primary care office
visits
• Approach to urinary infection differs
according to age, sex and underlying
diseases
• Acute uncomplicated lower
tract infection in women
• Recurrent lower tract
infection in women
• Acute upper tract infection
(pyelonephritis) in women
• UTIs in men, children and
geriatric population
• The most common causes of
UTI infections (about 80% to
90%) are Escherichia coli
bacterial strains that usually
inhabit the colon.
• Klebsiella, Pseudomonas,
Enterobacter, Proteus,
Staphylococcus, Mycoplasma,
Chlamydia, Serratia and
Neisseria
• Some parasites (Trichomonas,
Schistosoma) also may cause
UTIs
Differential Diagnosis
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Vaginal atrophy
Vaginitis
Urethritis
Interstitial cystitis
Prostatitis
Urethritis
Risk factors
• %10-20% of women have epithelium
makes easy adherence of m.o.
• Colonization of vagina – use of
contaceptive cream-jelly, nonoxynol-9
• Barrier use
• Shorter distance between urethra and
anus- sexual intercourse
• Fecal incontinence
• Stasis of baldder
Risk factors of pyelonephritis
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Recurrent urinary tract infection
Diabetes mellitus
Recent incontinence
New sexual partners
Use of spermicide
Mother with history of UTI
History
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Urinary frequency
Dysuria
Nocturia
Suprapubic discomfort
Urgency
Malodorous urine
Probability of symptoms
• Dysuria+nocturia: %65
• Malodorus urine and nocturia or urgency
or recurrence of symptoms fallowing UTI:
90%
• Vaginal complaints, external dysuria: STI
/vaginitis
• Upper urinary infection (pyelonephritis)
Fever
Chills
Flank pain
Abdominal pain
Vomitting
Physical Examination
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Vital signs
Palpation of mid and lower abdomen
Percussion of flanks
Genital examination (prostatitis, vaginitis)
Red Flags for a complicated
Infection
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Male gender
Infant or geriatric age
Symptoms more than 7 days
Immunosuppressive condition
Diabetes mellitus
Episode of acute pyelonephritis within the past
year
• Known anatomic abnormality
• Fever
• Flank pain or tenderness
Laboratory Tests: Collecting
specimen
• Midstream urine: First
few seconds of urine
is not collected
• Catheterization in
infants and very
young
• Plastic bag collection
Urinanalysis
Dry reagent test strip (dipstick)
• Leukocyte esterase: Detects presence of
esterase from WBC. False positive: chlamydial
infection, high urine pH, high levels of urine
glucose, certain drugs
• Nitrite: Dietary nitrates are excreted into the
urine and converted to nitrit by bacteria
False negative: Gram positive ones and
Pseudomonas don’t convert nitrate to nitrite, E.
Coli need sometime to convert and vegeterians
• Leucocyte esterase +
nitrite: both positive and
both negative is better
predictor of infection
presence or absence
• Blood:Peroxidase like
activity
False positive: Myoglobin,
peroxidase producing
bacteria
Direct microscopy:
• Centrifuge 10 ml freshly
voided urine, decanting
the urine than
resuspending the
sediment
• Leukocyte:High-power
field (x 400) 5 or more
• Bacteria: 10 or more ; if
no bacteria rule out
• White cell casts
Urine Culture
• Not cost-effective in routine care
• Do it:
- Children, men, geriatric population
- Patients with red flags
- Younger women: Risk of upper tract infection
- Infection with bacteria not likely respond firt line
antibiotics
Management: Acute uncomplicated
lower tract infection in women
• Telephone directed
• Ampiric antibiotic treatment: 3 days or 7
days regimen
- Trimethoprim/sufamethoxazole
- Nitrafurantoin (7 days)
- Fluoroquinolone (e.g.ciprofloxacine)
• Occult pyelonephritis: 7 days regimen
• Phenazopyridine analgesia for severe
dysuria
Management: Acute uncomplicated
lower tract infection in women
• Recurrent infection: Urine culture and treat in the
same way
• Prevention:
• Patient initiated treatment
• Unsweetened cranberry juice
• Increasing fluid intake
• 3 or more a year related STI: single dose
antibiotic after intercourse
• Behavioral advices( not using pantyhose, wiping
font to back, postcoital voiding) have not been
proven effective.
Acute Pyelonephritis inYounger
Women
• Women who are medically stable
and maintaining hydration with oral
intake: Can be treated as
outpatients
• Women who, because of severity
of infection or underlying disability,
are not medically stable or unable
to take oral fluids or medications:
Refer for hospitilization
• Women who have been infection
complicated by abcess or
obstruction, regardless of ability to
take fluids by mouth
Adult Men with UTIs
• Differentiate lower or upper
UTIs
• Differentiate prostatitis and
urethritis
• Treat as complicated UTIs:
- Order urine culture
pretreatment
- First line usually
floroquinalone 14 days
• After second infection or first
episode of pyelonephritis:
Imaging for anatomic
abnormality or nephrolithiazis
UTIs in Older Adults
• Atypic symptoms: Mental status change,
tachpnea, tachycardia, fever, gait instability, or
falls
• Pretreatment urine culture
• 3 days regimen acceptable but 7-14 days are
prefered
• Frequent relapses: Search for nephrolithiazis or
urinary retention
• Elder women: Local estrogen decrease
repeating gram negative organisms
UTIs in Children
• Girls: 5-8 %
• Boys: 1-2 %
• Noncircumsized v
circumsized
• Young children:
perineal colonization
• Older children: stasis
• Vesicoureteral reflux:
30-50 %
• Vesicoureteral reflux:
30-50 %
• Recurrent infection
and renal scarring
• First year of life: unexplained fever
consider UTIs
• Neonates: Late-onset jaundice, Poor
weight gain, Irritability, Hypothermia
• Infants: Diarrrhea , vomiting, failure to
thrive
• School children: Back pain, abdominal
pain, incontinence
• Urinanalysis has limited sensitivity in
young children; Urine culture routinely
• Older children dipstick and urine
microscopy have similar sensitivity and
specifity as in adults
• Older than 3 mo: 3 days antibiotic regimen if no
systemic signs
TMP/SMX
Amoxicillin/clavunate
Nitrafurantoin
Third generation cephalosporins
• Younger than 3 mo: refer for hospitilization;
treated with parenteral antibiotics
• Urine culture after cpmpletion of treatment to
confirm successful treatment
Imaging studies to detect anatomic or
functional abnormalities:
• < 2 yrs
• > 2 yrs with recurrent infections
• >2 yrs with single episode of acute
pyelonephritis
