Updated: 6/12/2019

Urinary Tract Infections

Topic
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Questions
15
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Evidence
11
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Overview
 

 
Snapshot
  • A 25-year-old, G1P0, woman who is 14 weeks pregnant presents to her obstetrician for routine prenatal screening. She reports feeling well except for mild nausea. She denies any dysuria, urinary frequency, or abnormal bleeding from the vagina or seen in the urine. A clean catch mid-stream urine sample is collected for urine culture. Urine culture reveals bacteriuria of ≥ 105 cfu/mL. She is started on oral nitrofurantoin for 5 days. (Asymptomatic bacteriuria in pregnancy)
Introduction
  • Clinical definition
    • urinary tract infections (UTI) can either be asymptomatic or symptomatic and encompasses
      • asymptomatic bacturia (ASB)
        • there is bacteria in the urinary tract; however, the patient has no symptoms
        • typically patients do not require treatment 
          • pregnant women require screening and treatment
            • this is because ASB in pregnancy is associated with
              • pre-term birth
              • perinatal death
              • pyelonephritis in the mother
      • cystitis
      • prostatitis
      • pyelonephritis
    • it is important to distinguish between uncomplicated and complicated UTI
      • uncomplicated UTI
        • this describes acute cystitis or pyelonephritis in outpatient women who are not pregnant and do not have anatomic abnormalities or instrumentation within the urinary tract
      • complicated UTI
        • this describes UTI that is not uncomplicated
  • Epidemiology
    • incidence
      • 50-80% of women acquire at least 1 UTI
      • 20-30% of women with 1 UTI have recurrent infections
    • demographics
      • more common in women, elderly, and infants
    • location
      • bladder
      • prostate
      • kidneys
    • risk factors
      • female
        • due to the shorter female urethra 
      • benign prostatic hyperplasia
      • frequent sexual intercourse
      • history of UTI
      • incontinence
      • diabetes mellitus
      • vasicoureteral reflux
      • spermicide use
      • indwelling catheter
        • intermittent catheterization can prevent a UTI
  • Pathogenesis
    • in most cases bacteria ascends from the urethra to the bladder (cystitis)
      • bacterial organisms can further ascend through the ureter and infect the kidney causing a renal parenchymal infection (pyelonephritis)
      • note that infection and symptom development depends on the
        • host
          • e.g., genetic background, behavioral factors, and underlying disease
        • pathogen
        • environmental factors
          • e.g., vaginal microflora, medical devices (e.g., indwelling catheters), and urinary retention
        • for example, voiding and the host's innate immune response eliminates bacterial colonization in the bladder after sexual intercourse
          • however, an indwelling catheter, stone, or any other foreign body provides a surface where bacteria can colonize
      • hematogenous spread to the urinary tract can also result in a UTI; however, this is rare
        • e.g., Salmonella, S. aureus, and Candida
  • Prognosis
    • ASB in elderly or catheterized patients does not increase the risk of death
    • recurrent UTI in children and adults does not result in chronic pyelonephritis or renal failure
      • this is true when there are not anatomic abnormalities
 
Microbiology of Urinary Tract Infections
Microbe
Findings
Comments
E. coli 
  • Green metallic sheen on EMB agar
  • Most common cause of UTI
S. saprophyticus
-
  • Second most common cause in sexually active women
K. pneumoniae
  • Large mucoid capsule and viscous colonies
  • Third most common cause
S. marcescens
  • Red pigment production by select strains
-
Enterococcus -
  • Typically a nosocomial infection that is drug-resistant
P. mirabilis 
  • "Swarming" appearance on agar
  • Urease positive
  • Can result in struvite stone formation
-
P. aeruginosa
  • Blue-green pigment
  • Typically a nosocomial infection that is drug-resistant
 
Presentation
  • Symptoms/physical exam/findings
    • ASB
      • asymptomatic patient with an incidental finding of bacteruria on urine culture
    • cystitis
      • dysuria
      • urinary frequency
      • urgency
      • nocturia
      • suprapubic discomfort
      • gross hematuria
    • prostatitis
      • dysuria
      • frequency
      • pain in the prostatic pelvic or perineal area
      • bladder outlet obstruction
      • fever and chills
    • pyelonephritis 
      • fever
        • this is the main feature that distinguishes pyelonephritis from cystitis
      • costovertebral angle pain
        • may be absent in mild pyelonephritis
      • obstructive uropathy in patients with diabetes
        • this is secondary to acute papillary necrosis that results in the papillae to slough and subsequently obstruct the ureter
      • emphysematous pyelonephritis in patients with diabetes
        • gas is produced in the renal and perinephric areas
Imaging
  • Ultrasound
    • renal and bladder
    • indications
      • in children < 2-years-old with a first febrile UTI  
      • in children who are not appropriately responding to antimicrobial treatment of UTI
      • in children with recurrent UTIs
      • family history of renal or urologic disease
    • unless severe illness or failure to respond to therapy, imaging should occur after resolution of the acute illness
  • Voiding cystourethrogram
    • indication
      • test of choice to determine the presence of a vesicourethral reflux
      • 2 or more febrile UTIs in children
      • anomalies seen on renal ultrasound
      • high fever with pathogen other than E. coli
Studies
  • Labs
    • urine dipstick
      • nitrite positivity suggests an E. coli infection or other infection of the Enterobacteriaceae family
      • leukocyte esterase positive
      • urease positivity
        • S. saprophyticus
        • Proteus
          • coffin lid stones 
        • Klebsiella
    • urinalysis
      • > 10 white blood cells (WBCs)/mL
      • > 1000 CFU/mL
      • white blood cell casts 
        • a diagnostic finding of an upper urinary tract infection (e.g., pyelonephritis)
    • urine culture
      • gold standard for diagnosing UTI
      • must be sent in pregnant patients to determine sensitivity 
    • assess for pregnancy 
  • Histology
    • chronic pyelonephritis
      • "thyroidization" of tubules due to eosinophilic casts contained in the tubules
Differential
  • Acute hemorrhagic cystitis
    • can be caused by adenovirus 
  • Urethritis
  • Nephrolithiasis
  • Genitourinary malignancy
Treatment
  • Medical
    • TMP-SMX or nitrofurantoin
      • indications
        • first-line for uncomplicated UTI
          • second-line agents include a fluoroquinolone or β-lactam
        • nitrofurantoin, ampicillin, and cephalosporins can be used in the treatment of UTI in pregnant women  
          • parenteral β-lactam with or without aminoglycosides is used in pregnant women with pyelonephritis
          • sulfonamides should not be used due to its possible teratogenic effects (in first trimester) and kernicterus development (near term)
          • fluoroquinolones should also be avoided in pregnancy due to its negative effect on the development of fetal cartilage
        • TMP-SMX or a fluoroquinolone is used in the treatment of prostatitis
        • TMP-SMX can be used for uncomplicated or resolving pyelonephritis in a stable patient 
    • fluoroquinolones (e.g., ciprofloxacin)
      • indication
        • first-line for acute uncomplicated pyelonephritis 
    • fluconazole
      • indication
        • first-line treatment for Candida-related UTI
    • amoxicillin-clavulanate 
    • no treatment 
      • indicated in asymptomatic bacteriuria in non-pregnant patients
  • Operative
    • nephrectomy
      • indications
        • treatment for xanthogranulomatous pyelonephritis
    • percutaneous drainage
      • indications
        • treatment for emphysematous pyelonephritis and it may be followed by elective nephrectomy
Complications
  • Uncomplicated UTI
    • complications are uncommon
  • Complicated UTI
    • bacteremia
    • urosepsis
    • systemic inflammatory response syndrome (SIRS)
    • renal and perinephric abscess
    • emphysematous pyelonephritis
    • xanthogranulomatous pyelonephritis
      • associated with long-term urinary tract obstruction and infection
        • this results in chronic destruction of the renal parenchyma via a granulomatous process
    • malakoplakia
    • renal papillary necrosis
  • UTI in pregnancy
    • pyelonephritis
    • sepsis
    • chorioamnionitis
    • preterm labor
    • low birth weight
    • hypertension and pre-eclampsia
  • UTI in men
    • acute or chronic prostatitis
    • urethritis
    • acute epididymitis
    • orchitis
 

 

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Questions (15)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M2.RL.1) A 74-year-old woman presents to the emergency department for shortness of breath and bilateral lower extremity pitting edema. She has had exacerbations like this in the past and notes that she has not been taking her home heart medications as scheduled. Review of systems is negative for any other symptoms including GI, urinary, and musculoskeletal symptoms. Physical exam reveals bilateral pulmonary crackles, lower extremity pitting edema that extends to the hip, and no abdominal tenderness. Neurological exam is unremarkable and the patient is at her baseline mental status. She is subsequently started on BiPAP, given furosemide, and admitted to the hospital. Routine admission workup includes urinalysis, which shows >100,000 cfu/mL of E. coli. She has no known drug allergies. Which of the following is the most appropriate treatment for this patient for this finding? Review Topic

QID: 102803
1

Ceftriaxone

32%

(36/113)

2

Levofloxacin

16%

(18/113)

3

Nitrofurantoin

9%

(10/113)

4

No treatment

39%

(44/113)

5

Trimethoprim-sulfamethoxazole

2%

(2/113)

M2

Select Answer to see Preferred Response

PREFERRED RESPONSE 4
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(M2.RL.4875) A 17-year-old woman presents to the emergency department with dysuria. She denies any hematuria or dyspareunia. Her last menstrual period was 3 weeks ago, and she denies any recent sexual activity. Her temperature is 99.7°F (37.6°F), blood pressure is 127/67 mmHg, pulse is 90/min, and respirations are 17/min. An unusual odor is detected on inspection of the vagina and some gray discharge is noted. Speculum exam reveals a normal cervix and a bimanual exam is unremarkable for adnexal masses or tenderness. What is the next best step in management? Review Topic

QID: 109993
1

Complete blood count (CBC)

0%

(0/2)

2

Urinalysis and Pap smear

0%

(0/2)

3

Urinalysis, urine culture, and potassium hydoxide prep (KOH)

100%

(2/2)

4

Urinalysis, urine culture, KOH prep, and urine pregnancy test

0%

(0/2)

5

Urinalysis, KOH prep, and nucleic acid amplification tests for N. gonorrhea and C. trachomatis

0%

(0/2)

M2

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

(M2.RL.4867) A 26-year-old woman presents to the emergency department for shortness of breath. She was walking up a single flight of stairs when she suddenly felt short of breath. She was unable to resolve her symptoms with use of her albuterol inhaler and called emergency medical services. The patient has a past medical history of asthma, constipation, irritable bowel syndrome, and anxiety. Her current medications include albuterol, fluticasone, loratadine, and sodium docusate. Her temperature is 99.5°F (37.5°C), blood pressure is 110/65 mmHg, pulse is 100/min, respirations are 24/min, and oxygen saturation is 85% on room air. On physical exam the patient demonstrates poor air movement and an absence of wheezing. The patient is started on an albuterol nebulizer. During treatment, the patient's saturation drops to 72% and she is intubated. The patient is started on systemic steroids. A Foley catheter and an orogastric tube are inserted, and the patient is transferred to the MICU. The patient is in the MICU for the next seven days. Laboratory values are ordered as seen below.

Hemoglobin: 11 g/dL
Hematocrit: 33%
Leukocyte count: 9,500 cells/mm^3 with normal differential
Platelet count: 225,000/mm^3

Serum:
Na+: 140 mEq/L
Cl-: 102 mEq/L
K+: 4.0 mEq/L
HCO3-: 24 mEq/L
BUN: 21 mg/dL
Glucose: 129 mg/dL
Creatinine: 1.2 mg/dL
Ca2+: 10.1 mg/dL
AST: 22 U/L
ALT: 19 U/L

Urine:
Color: amber
Nitrites: positive
Leukocytes: positive
Sodium: 12 mmol/24 hours
Red blood cells: 0/hpf

Which of the following measures would have prevented this patient's laboratory abnormalities? Review Topic

QID: 109553
1

Nitrofurantoin

2%

(1/49)

2

TMP-SMX

4%

(2/49)

3

Sterile technique

20%

(10/49)

4

Avoidance of systemic steroids

0%

(0/49)

5

Intermittent catheterization

61%

(30/49)

M2

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PREFERRED RESPONSE 5

(M2.RL.4725) A 28-year-old G2P1001 presents for a routine obstetric visit in her 36th week of pregnancy. She has a history of type I diabetes controlled by insulin and delivered 1 child by normal spontaneous vaginal delivery 2 years ago. Earlier in this pregnancy, she had 2 episodes of burning with urination and frequent urination. Urinalysis each time confirmed a urinary tract infection, and both urine cultures isolated organisms sensitive to nitrofurantoin. Her symptoms resolved with 10-day courses of nitrofurantoin. She has no complaints today. Urinalysis is positive for leukocyte esterase and nitrites. Which of the following is the best next step in management? Review Topic

QID: 108573
1

No treatment

0%

(0/20)

2

Admit to the hospital and treat with intravenous ceftriaxone

0%

(0/20)

3

Treat with oral trimethroprim-sulfamethoxazole for 10 days then continue for prophylaxis until delivery

15%

(3/20)

4

Treat with oral nitrofurantion for 10 days

5%

(1/20)

5

Treat with oral nitrofurantion for 10 days then continue for prophylaxis until delivery

80%

(16/20)

M2

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PREFERRED RESPONSE 5

(M2.RL.4675) A 32-year-old G2P2 at 33 weeks and 4 days of gestation presents to the emergency room with low-grade fever, mild low back pain, and dysuria for 1 day. She has a history of urinary tract infections, including one during this current pregnancy that was treated successfully with cephalexin. On examination, she is nontoxic but mildly uncomfortable; she has CVA tenderness on her right side. Her urinalysis is positive for leukocyte esterase and nitrites, and she is admitted to the hospital for IV antibiotics with ceftriaxone. Her present condition places her at increased risk for which of the following: Review Topic

QID: 107218
1

Low birth weight

0%

(0/0)

2

Pre-eclampsia

0%

(0/0)

3

Postpartum hemorrhage

0%

(0/0)

4

Preterm labor

0%

(0/0)

5

Post-term labor

0%

(0/0)

M2

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

(M2.RL.47) A 37-year-old female with a history of type II diabetes mellitus presents to the emergency department complaining of blood in her urine, left-sided flank pain, nausea, and fever. She also states that she has pain with urination. Vital signs include: temperature is 102 deg F (39.4 deg C), blood pressure is 114/82 mmHg, pulse is 96/min, respirations are 18, and oxygen saturation of 97% on room air. On physical examination, the patient appears uncomfortable and has tenderness on the left flank and left costovertebral angle. Which of the following is the next best step in management? Review Topic

QID: 104932
1

Obtain an abdominal CT scan

0%

(0/6)

2

Obtain blood cultures

17%

(1/6)

3

Obtain a urine analysis and urine culture

83%

(5/6)

4

Begin intravenous treatment with ceftazidime

0%

(0/6)

5

No treatment is necessary

0%

(0/6)

M2

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(M2.RL.61) A 1-year-old female presents to the emergency department with 2 days of fever up to 103ºF. During the course of her work-up, a urine culture reveals gram negative rods and a urinary tract infection (UTI) is diagnosed. She is placed on ceftriaxone and quickly defervesces. Follow-up of the urine culture reveals the causal bacteria was E. coli, without any concerning resistance patterns and was susceptible to ceftriaxone. This is her first UTI and there is no family history of renal abnormalities or vesicourethral reflux. In addition to her current therapy, what additional steps should be taken during the management of this child's UTI? Review Topic

QID: 104603
1

Prophylactic antibiotic therapy to prevent future UTIs

0%

(0/0)

2

Voiding cystourethrogram

0%

(0/0)

3

Renal bladder ultrasound

0%

(0/0)

4

Repeat urine culture

0%

(0/0)

5

Renal scintigraphy

0%

(0/0)

M2

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(M3.RL.3) A 29-year-old G1P0 woman at 24 weeks gestation presents to her physician with complaints of burning with urination, and she reports that she has been urinating much more frequently than usual over the past several days. She otherwise is doing well and has experienced no complications with her pregnancy or vaginal discharge. Her temperature is 97.5°F (36.4°C), blood pressure is 112/82 mmHg, pulse is 89/min, respirations are 19/min, and oxygen saturation is 98% on room air. Examination is significant for suprapubic discomfort upon palpation and a gravid uterus. There is no costovertebral angle tenderness. Urinalysis shows increased leukocyte esterase, elevated nitrites, 55 leukocytes/hpf, and bacteria. The physician prescribes a 7-day course of nitrofurantoin. Which of the following is the next best step in management? Review Topic

QID: 103294
1

Add ciprofloxacin to antibiotic regimen

20%

(2/10)

2

Add penicillin to antibiotic regimen

0%

(0/10)

3

Perform a renal ultrasound

10%

(1/10)

4

Send a urine culture

10%

(1/10)

5

Test for gonorrhea and chlamydia

50%

(5/10)

M2

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

(M2.RL.26) A 23-year-old pregnant woman at 22 weeks gestation presents with burning upon urination. She states it started 1 day ago and has been worsening despite drinking more water and taking cranberry extract. She otherwise feels well and is followed by a doctor for her pregnancy. Her temperature is 97.7°F (36.5°C), blood pressure is 122/77 mmHg, pulse is 80/min, respirations are 19/min, and oxygen saturation is 98% on room air. Physical exam is notable for an absence of costovertebral angle tenderness and a gravid uterus. Which of the following is the best treatment for this patient? Review Topic

QID: 103389
1

Ampicillin

20%

(1/5)

2

Ceftriaxone

60%

(3/5)

3

Ciprofloxacin

0%

(0/5)

4

Doxycycline

20%

(1/5)

5

Nitrofurantoin

0%

(0/5)

M2

Select Answer to see Preferred Response

PREFERRED RESPONSE 5
ARTICLES (11)
Topic COMMENTS (39)
Private Note