Urinary Tract Infections/Pyelonephritis

 Definitions
o Uncomplicated
 Lack structural or functional abnormalities and otherwise healthy
 Example
o College age female with no other health concerns
o Complicated
 Individual has structural or functional abnormalities such as
 Enlarged prostate
 Congenital abnormality of the urinary tract
 Kidney stone
 Neurological deficits effecting normal urine flow
 Indwelling catheter
o Catheter associated urinary tract infection (CA-UTI)
 Infection that occurs in someone that currently is catheterized or within
the last 48 hours and has signs/symptoms of UTI with ≥103cfu/ml
 Associated with longer duration of catheterization
 Etiology
o Bacteria that cause urinary tract infections usually originate from the GI tract
 Most common bacterial causes of uncomplicated UTIs include
 E. Coli (80% to 90%)
 Klebsiella pneumoniae
 Proteus species
 Enterococcus species
 Most common bacterial causes of complicated UTIs include
 E. Coli (<50% of cases)
 Enterococci species
 Klebsiella pneumoniae
 Enterobacter species
 Staphylococci species
 Candia species
o Catheters bypass defense mechanisms allowing for easier access for bacteria
 Most common bacterial causes of CA-UTIs
 E. Coli (<30%)
 Klebsiella species
 Serratia species
 Citrobacter species
 Pseudomonas aeruginosa
 Proteus mirabilis
 Morganella morganii
 Providencia stuartii
  Staph aureus
 Coagulase-negative staphylococcus
 Enterococcus species
 Pathophysiology
o Route of infection
 Ascending
 Hematogenous
 Descending or the pathogen disseminates from another location
or primary infection site
 Example:
o Staph aureus bacteremia can cause renal abscesses
 Lymphatic
 Signs/symptoms
o Lower UTI
 Dysuria
 Increased urgency/frequency
 Suprapubic heaviness
o Upper UTI
 Flank pain
 Fever
 Nausea
 Vomiting
o Lab tests
 Bacteriuria
 Pyuria
 Nitrite-positive urine
 Gram negative organisms
o Note: pseudomonas aeruginosa does not produce nitrites
 Leukocyte esterase positive
o Elderly patients can present with the following signs/symptoms
 Acute mental status changes
 Change in eating habits
 GI symptoms
o Culture
 Midstream clean-catch (preferred method)
 Urethral opening is cleaned
 Patient is to void 20 to 30 ml, discard, and then collect the next
void
 Catheterization
 Suprapubic Bladder aspiration
 Insert needle directly into the bladder and aspirate urine
 Uncomplicated UTI Treatment
o Pain relief
 Phenazopyridine (AZO ®)
 OTC product
 Dose
o 100 mg to 200 mg PO TID
 Adverse effects
o Red-orange discoloration of body fluids
o Rash
o Anaphylaxis
o Hemolytic anemia
o Acute renal failure
o Antibiotics
 Nitrofurantoin 100 mg twice daily for 5 days
 Sulfamethoxazole/Trimethoprim 800 mg/160 mg twice daily for 3 days
 Fosfomycin 3 grams once
 Ciprofloxacin or levofloxacin for 3 days
 Amoxicillin/Clavulanate, cefdinir, cefaclor, and cefpodoxime- proxetil for
3 to 7 days
o Pregnancy
 Bacteriuria without signs/symptoms should be treated!
 Nitrofurantoin should not be used during the first trimester as it has been
linked to birth defects
 Sulfamethoxazole/trimethoprim should be avoided in the first trimester
and ≥32 weeks gestation
 Inhibits folate and is associated with neural tubal defects
  Pyelonephritis
o Antibiotics
 Ciprofloxacin 500 mg twice daily for 7 days
 Levofloxacin 750 mg daily for 5 days
 Sulfamethoxazole/trimethoprim 800 mg/160 mg twice daily for 14 days
 Intravenous beta lactam or aminoglycoside followed by oral beta lactam
for 10 to 14 days

 CA-UTI
o Treatment is similar to above with a duration of 7 days for patients with prompt
symptom resolution or 14 days if the patient continuous to have fever or other
signs/symptoms
 Studies

5-Day Open-label/ Included women ≥18 513 patients Primary outcome:

Nitrofurantoi analyst years old with at least 1 enrolled  70% of
n vs. Single blinded, symptom of UTI and a patients
Dose multicenter urine dipstick test E. Coli (61%) receiving
Fosfomycin randomized positive for either Klebsiella nitrofurantoi
trial nitrite or leukocyte spp. (7%) n vs 58% of
occurring in esterase Enterococcu patients
Geneva, s spp. (7%) receiving
Switzerland, Excluded: Proteus spp. fosfomcyin
Lodz, Poland,  Pregnant (7%) had clinical
and Petah-  Symptoms of resolution 28
Tiqva Israel upper UTI days after
(fever/chills/flan treatment
Randomized k pain) (P=0.004)
patients to
either Secondary outcome:
nitrofurantoi  75% (nitro)
n macro- vs 66%
crystals 100 (fosfo) had
mg TID or 3 clinical
grams of oral resolution at
fosfomycin 14 days
once (P=0.03)
References:
1. Fernaandez JM and Coyle EA. Urinary Tract Infections and Prostatitis. In:
Pharmacotherapy: A Pathophysiologic Approach. 11th edition. Dipiro JT, Yee GC, Posey
M, Haines ST, Nolin TD, and Ellingrod V. New York: McGraw Hill; 2020.
2. Gupta K, Hooton TM, et al. International Clinical Practice Guidelines for the Treatment
of Acute Uncomplicated Cystitis and Pyelonephritis in Women: A 2010 Update by the
Infectious Diseases Society of America and European Society for Microbiology and
Infectious Diseases. Clinical Infectious Diseases. 2011; 52(5):103-20. DOI:
10.1093/cid/ciq257.
3. Hooton TM, Bradley SF, et al. Diagnosis, Prevention, and Treatment of Catheter
Associated Urinary Tract Infection in Adults: 2009 Internal Clinical Practice Guidelines
from the Infectious Diseases Society of America. Clinical Infectious Diseases.
2010;50:625-63. DOI: 10.1086/650482.
4. Huttner A, Kowalcyz A, and Turjeman Adi. Effect of 5-Day Nitrofurantoin vs Single Dose
Fosfomycin on Clinical Resolution of Uncomplicated Lower Urinary Tract Infection in
Women: A randomized Clinical Trial. JAMA. 2018;319(17):1781-89. DOI:
10.1001/jama.2018.3627.