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TRACT
INFECTION
Course Outline
THERAPEUTIC MANAGEMENT
DIAGNOSTIC TOOLS
(I) History
- One symptom of UTI (dysuria, frequency,
hematuria, or back pain) and without complicating
factors, the probability of acute cystitis or
pyelonephritis is 50%.
- A combination of dysuria and urinary frequency in the
absence of vaginal discharge increases the probability
of UTI to 96%
- Significant concerns: STD [caused by Chlamydia
- Xanthogranulomatous Pyelonephritis occurs when trachomatis], may be inappropriately treated as UTI.
chronic urinary obstruction together with chronic Differential dx to be considered when women present
infection leads to destruction of renal tissue. with dysuria includes cervicitis, vaginitis, herpetic
urethritis, interstitial cystitis, and noninfectious vaginal
or vulvar irritation.
- Pt with more than one sexual partner and inconsistent
use of condom are at high risk for both UTI & STD.
(II) URINE DIPSTICK, URINALYSIS, AND URINE
CULTURE
- If a woman with acute cystitis is forcing fluids and
voiding frequently, the dipstick test for nitrite is less
likely to be positive, even when E. coli is present.
- Urine dipstick test can confirm the diagnosis of
uncomplicated cystitis in a patient with a reasonably
high pretest prob ability of this disease. Blood in the
urine may suggest dx of UTI.
- Negative dipstick test is not sufficiently sensitive to
rule out bacteriuria in pregnant women, in whom it is
important to detect all episodes of bacteriuria.
- Urine microscopy reveals pyuria in nearly all cases of
cystitis and hematuria. Counts of bacteria are less
accurate than are counts of RBC & WBC.
- Detection of bacteria in urine culture is diagnostic gold hx, previous episodes of pyelonephritis, antimicrobial
standard of UTI, culture results don’t become available resistance, recent UT manipulations.
until 24h after the patient’s presentation.
UTI IN PREGNANT WOMEN
DIAGNOSTIC APPROACH
Nitrofurantoin, ampicillin, and cephalosporins
UNCOMPLICATED CYSTITIS IN WOMEN Sulfonamides: avoided due to teratogenic effect and
possible role in the development of kernicterus.
If reliable history can’t be obtained, then perform
Fluoroquinolones are avoided d/t adverse effect on
urine dipstick test is a must.
fetal cartilage development.
Negative dipstick result: urine culture, close clinical
Pregnant ASB: 4-7 days single dose therapy
follow up, and pelvic exam is recommended.
Overt pyelonephritis: parenteral B-lactam therapy with
COMPLICATED UTI or without aminoglycosides.
Antimicrobial therapy is warranted for any UTI that is truly ASYMPTOMATIC BACTERIURIA
symptomatic.
Do not warrant antimicrobial therapy.
UNCOMPLICATED CYSTITIS (WOMEN)
CATHETER-ASSOCIATED UTI
TMP-SMX is the first-line agent for treatment.
Note for collateral damage Remove biofilm-associated organisms that could serve
Minimal effect on fecal flora: pivmecillinam, as nidus for reinfection. Long term catheters have
Fosfomycin, and nitrofurantoin. occult pyelonephritis.
Second line agent: B-lactam but it fails to eradicate 7-14 days of antibiotics
uropathogens from vaginal reservoir. Best strategy: intermittent catheterization or avoid
Urinary analgesics [phenazopyridine] speed resolution insertion of unnecessary catheters & to remove
of bladder discomfort but can cause significant nausea. catheters once they are no longer necessary.
The downside is that women who really do have
CANDIDURIA
cystitis endure discomfort for a longer period and may
meanwhile progress to pyelonephritis. Fluconazole 200-400mg for 7-14 days is the first line
regimen for Candida infection.
PYELONEPHRITIS
For Candida isolates with high levels of resistance to
Acute uncomplicated pyelonephritis: fluoroquinolones fluconazole, oral flucytosine and/ or parenteral
orally or parenterally amphotericin B are options.
Combinations of B-lactam and B-lactamase inhibitors
or carbapenem are used in pt with more complicated PREVENTION OF RECCURENT UTI (WOMEN)
A preventive strategy is indicated if recurrent UTIs are
interfering with patient’s lifestyle.
PROGNOSIS