Urinary Tract Infection (UTI) Overview

Urinary Tract Infection (UTI) in People 14 Years and Older

• These notes provide optimal use guidelines for clinicians, but don't replace clinical expertise or judgement.

General Information

Terminology

• Uncomplicated UTI: Acute or recurrent cystitis or pyelonephritis in women without risk factors.
• Complicated UTI: Infection with risk factors, including:
  • Anatomical or functional abnormalities
  • Poorly controlled diabetes or immunosuppression
  • Being male
  • Recent urologic manipulation
  • Chronic kidney disease
  • Catheter use or urinary obstruction
• Recurrent UTI: More than two infections per six months or three per year.
• Asymptomatic Bacteriuria: Significant bacterial count in urine without symptoms.
• Urosepsis: UTI with systemic inflammation, possibly leading to organ dysfunction and risk of fatality.

Uropathogens

• Detection of bacteria doesn't always mean infection (e.g., contamination).
• Consider the clinical picture to determine if the identified bacteria is a pathogen.
• Possible bacteria include:
  • Escherichia coli, Klebsiella pneumoniae, Proteus mirabilis, Enterobacter sp.
  • Pseudomonas aeruginosa, Staphylococcus aureus, Staphylococcus saprophyticus, Aerococcus urinae, Enterococcus sp.
  • Note: Repeated detection of Proteus mirabilis may require investigation as it may point to a renal stone

Diagnostic Approach

• Diagnosis combines:
  • Symptoms and signs of UTI
  • Risk factors for complications
  • Medical lab tests (if needed)
  • Exclusion of other conditions

Clinical Presentation

• Symptoms include:
  • Cystitis: Dysuria (pain when urinating), urgent need to urinate, frequent need to urinate, suprapubic pain, hematuria (blood in urine)
  • Pyelonephritis: Fever, back or flank pain, possibly cystitis symptoms, nausea, vomiting
  • Vitals are normal with cystitis, and cloudy or bad-smelling urine itself is not an indicator

Physical Examination

• Consider checking vitals in settings such as fever, confusion or altered mental state
• If suprapubic discomfort or back/flank pain is flagged, consider abdominal or lumbar examination
• Consider checking factors related to ITs with genital and pelvic exams
• Manifestations can be non-specific or atypical for the elderly (e.g., change in mental state/ confusion)

Different Diagnosis

• Symptom overlaps may point to other conditions like:
  • Vaginal infections
  • Gynecological issues
  • Epididymitis/prostatitis
  • Intra-abdominal infections
  • Sexually Transmitted Infections (STIs)
  • Urinary retention

Medical Lab Analysis

• Lab results should be interpreted with consideration to pretest probability (combination of symptoms) or errors may be possible
• Lab analysis preferred over urine dipstick, and follow lab procedures in order to ensure quality results.
• Absence of white blood cells and nitrites on urine dipstick makes cystitis unlikely
• Screening for asymptomatic bacteriuria isn't recommended without anticipation of mucosal damage
• Urine cultures not recommended as routine control unless clinical evolution is unfavorable

When and Why

• Consider type of clinical presentation when determining need for urine analysis and culture
• Urine culture must be collected before antibiotic dosage

Treatment Principles

Guidelines

• Prescription is geared towards preventing antibiotic resistance and minimizing harm to the microbiome.
• Local resistance data, previous culture results, and infection severity should influence antibiotic selection.
  • Local resistance should be consulted
• Pain can be managed with acetaminophen or ibuprofen (barring contraindications).
• There is not enough data about the effectiveness of urinary alkalinizers (e.g., citrate).

Further Notes

• Asymptomatic bacteriuria should not be treated with antibiotics unless urologic intervention where mucosal trauma is expected, and should be verified prior to prescriptions
• In uncomplicated cystitis cases, initiating antibiotics may be delayed (deferred treatment) if symptoms are mild-to-moderate, given the state, monitoring available and agreement from patient after a risks/benefit debate.

Antibiotic Therapy and Dysphagia

• Minimum antibiotic treatment duration should be prioritized to avoid antimicrobial resistance
• Longer duration may be considered for immunocompromised individuals, based on clinical judgement
• In cases of dysphagia, alternative modes of administration are indicated
• Be alert to local antibiotic resistance, and consult specialists
• Treatment durations are for effective antibiotic courses; longer durations may be needed based on the clinical portrait
• Re-administering antibiotics from within 3 months should not be re-prescribed without re-verifying sensitivity and resistance
• Withdrawal or replacement of a urinary catheter should go hand-in-hand with antibiotic treatment

Treatment for Acute Cystitis

• Consider type and situation and individual factors when selecting treatment plan
• For women, include Nitrofurantoin, Trimethoprim-Sulfamethoxazole or Fosfomycin
• Alternative for women with contraindications/resistance include Amoxicillin-clavulanate, Céfadroxil or Céfixime, or Fluoroquinolones
• For men includes Fluoroquinolones, Nitrofurantoin, Fosfomycin, Amoxicillin-clavulanate, Céfadroxil or Cefixime.

Treatment For Oral Pyelonephritis

General Treatment

• Oral options may be considered based on judgement, organization of services, and severity
• The selection of antibiotics should be consider type/resistance, risk, efficiency etcc

Possible Antibiotics

• Possible options are Trimethoprime-sulfamethoxazole or fluoroquinolones
• Some patients with contraindications can consider amoxicillin-clavulanate, cefadroxil, cefixime

Prevention and Recidivism

• Recommended to women include:
  • Increase Hydration
  • Regularizes intestinal transit
  • Wipe front to back after defecation
  • Urinate after intercourse etc
• Non-antimicrobial strategies include utilization of vaginal oestrogen for menopausal women and those in recidivism
• Consult with colleagues accordingly as needed

Strategies against antimicrobial resistance

• After excluding possible anatomical anomaly, strategies for preventing recidivism can include antibiophyaxis
• Post-coital should not be surpassing dosage of treatment
• Consider anti-microbial effects before utilization

Follow Up

• Re-evaluation of treatment, especially in conditions such as:
  • No improvement
  • Aggravating response
  • Rapid response
  • Medical analysis
  • Pathogen sensitivity via adjusted antibiotics -Oral pyelonephritis -Antibioprophylaxis --Evaluate effectiveness --innocuity and discuss strategy

Specialist Consultation

Hospital Situations

• Situations include bowel structure (with symptoms and signs), or a mental/social handicap
• Consultation in environments with pyelonephritis/nosocomial, AI, a suspicion of sepsis
• Also systemic symptoms, retention, catheter and other concerns

Further situations

• Considerations include: anatamolical of functional anomaly, UTIs in general, unexplained hematuria, or recidivism

Annexes

• Additional information on suggested ITS, risk factors associated with antibiotic resistance, etc