Urinary Tract Infection
Michele Ritter, M.D.
Argy Resident – Feb. 2007
Urinary Tract Infection
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Upper urinary tract Infections:
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Pyelonephritis
Lower urinary tract infections
Cystitis (“traditional” UTI)
 Urethritis (often sexually-transmitted)
 Prostatitis
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Symptoms of Urinary Tract Infection
Dysuria
 Increased frequency
 Hematuria
 Fever
 Nausea/Vomiting (pyelonephritis)
 Flank pain (pyelonephritis)
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Findings on Exam in UTI
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Physical Exam:
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CVA tenderness (pyelonephritis)
Urethral discharge (urethritis)
Tender prostate on DRE (prostatitis)
Labs: Urinalysis
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+ leukocyte esterase
+ nitrites
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More likely gram-negative rods
+ WBCs
+ RBCs
Culture in UTI
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Positive Urine Culture = >105 CFU/mL
Most common pathogen for cystitis,
prostatitis, pyelonephritis:
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Escherichia coli
Staphylococcus saprophyticus
Proteus mirabilis
Klebsiella
Enterococcus
Most common pathogen for urethritis
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Chlamydia trachomatis
Neisseria Gonorrhea
Lower Urinary Tract Infection Cystitis
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Uncomplicated (Simple) cystitis
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Complicated cystitis
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In healthy woman, with no signs of systemic
disease
In men, or woman with comorbid medical
problems.
Recurrent cystitis
Uncomplicated (simple) Cystitis
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Definition
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Diagnosis
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Dipstick urinalysis (no culture or lab tests needed)
Treatment
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Healthy adult woman (over age 12)
Non-pregnant
No fever, nausea, vomiting, flank pain
Trimethroprim/Sulfamethoxazole for 3 days
May use fluoroquinolone (ciprofoxacin or levofloxacin) in
patient with sulfa allergy, areas with high rates of bactrimresistance
Risk factors:
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Sexual intercourse
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May recommend post-coital voiding or prophylactic antibiotic
use.
Complicated Cystitis
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Definition
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Diagnosis
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Females with comorbid medical conditions
All male patients
Indwelling foley catheters
Urosepsis/hospitalization
Urinalysis, Urine culture
Further labs, if appropriate.
Treatment
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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
Special cases of Complicated
cystitis
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Indwelling foley catheter
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Try to get rid of foley if possible!
Only treat patient when symptomatic (fever, dysuria)
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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
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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)
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.
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Pyelonephritis
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Infection of the kidney
Associated with constitutional symptoms – fever, nausea,
vomiting, headache
Diagnosis:
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Treatment:
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Urinalysis, urine culture, CBC, Chemistry
2-weeks of Trimethroprim/sulfamethoxazole or fluoroquinolone
Hospitalization and IV antibiotics if patient unable to take po.
Complications:
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Perinephric/Renal abscess:
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Suspect in patient who is not improving on antibiotic therapy.
Diagnosis: CT with contrast, renal ultrasound
May need surgical drainage.
Nephrolithiasis with UTI
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Suspect in patient with severe flank pain
Need urology consult for treatment of kidney stone
Prostatitis
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Symptoms:
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Diagnosis:
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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:
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Pain in the perineum, lower abdomen, testicles, penis, and with ejaculation,
bladder irritation, bladder outlet obstruction, and sometimes blood in the
semen
Trimethoprim/sulfamethoxazole, fluroquinolone or other broad spectrum
antibiotic
4-6 weeks of treatment
Risk Factors:
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Trauma
Sexual abstinence
Dehydration
Urethritis
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Chlamydia trachomatis
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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:
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Azithromycin – 1 g po x 1
Doxycycline – 100 mg po BID x 7 days
Neisseria gonorrhoeae
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May present with dysuria, discharge, PID
Send UA, urine culture
Pelvic exam – send discharge samples for gram stain, culture, PCR
Treatment:
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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!
Question #1
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An 18-year old woman presents with
urinary frequency, dysuria, and lowgrade fever. Urinalysis shows pyuria and
bacilli. She has never had similar
symptoms or treatment for urinary tract
infection.
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?
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Question # 2
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An 18-year old woman present with her
third episode of urinary frequency,
dysuria, and pyuria in the past 4 months.
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?
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Question #3
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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.
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?
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Question # 4
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A 78-year old female presents with an
indwelling foley catheter and pyuria.
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?
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Question # 5
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58-year old man presents with his first
episode of urinary frequency and
dysuria. Urinalysis shows pyuria and
bacilli.
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?
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Question # 6
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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.
Question # 6
Question # 6
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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
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 HIVantibody, 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.
b)
c)
d)
e)
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!