An Overview of Urinary Tract

Infections and Pyelonephritis

Nicholas Corbin, PharmD
Franciscan Health – Indianapolis
Objectives

 Differentiate between criteria used to define complicated versus

uncomplicated urinary tract infections.
 Be able to list common bacterial causes of urinary tract infections
 Be able to interpret an antibiogram and apply information to create
an initial antimicrobial regimen
Patient Case
Subjective AA is a 41-year-old woman who presents to the emergency department due to
nausea, vomiting, lightheadedness, and dizziness. She reports her vomit looks
like coffee grounds. Patient also reports increased urinary frequency, pain when
going to the bathroom, and noticing some blood in her urine. 

Allergies: NKDA

PMHx: Cirrhosis (secondary to EtOH abuse), esophageal varices with banding

(2019), MDD, seizures

SHX: Lives with her boyfriend and two daughters

Tobacco use: 1 PPD x 10 years
EtOH: 5 glasses of wine/day

Insurance: Anthem HIP Basic

Patient case (continued)
Objective Vital Signs: Urinalysis
Ht: 68” Color Yellow
Wt: 65 kg Appearance Hazy
HR: 90
BP: 110/72 pH 5

Temp: 37.1oC Specific 1.03

gravity
Glucose Negative
Urine culture: pending
Ketone Negative
BMP:
Bilirubin Negative
Protein Negative
136 101 41 122
Blood Negative
3.8 26 1.2 Nitrite Negative
Leukocyte Negative
CBC: esterase
RBC 0-2
WBC 6-10
6.32 12.6 225
Bacteria Many
40 Epithelial None
cells
 Overview

Urinary Tract
Infection

Cystitis Prostatitis Pyelonephritis Urethritis

Catheter
Uncomplicated Complicated
Associated
Overview (continued)
Uncomplicated Complicated Catheter Pyelonephritis
Associated
• Lack structural or • Congenital lesion • Currently or • Inflammation of
functional • Indwelling within last 48 the kidneys
abnormalities catheter hours have been
• Pre-menopausal • Males catheterized
women • Neurological
deficit effecting
bladder function
• Prostatic
hypertrophy
Urinalysis
Bacteriuria
• 105 CFU/mL likely indicative of infection

Epithelial Cells
• Presence illustrates likely contaminate
• Goal: none or few

Leukocyte esterase
• Positive test indicates presence of WBCs

Nitrite
• Presence illustrates bacterial conversion from nitrates to nitrites
• What bacteria cause this?

Pyuria
• Defined as WBC >10 cells/mm3
 UTI Symptoms

Lower Upper Elderly

• Dysuria • Fever • Altered mental status

• Increased • Flank pain • Change in eating habits
frequency/urgency • Nausea
• Suprapubic heaviness • Vomiting
 How would you classify AA’s UTI?
A. Pyelonephritis
B. Uncomplicated
Question #1
C. Complicated
D. I don’t know, ID consult please!
 How would you classify AA’s UTI?
A. Pyelonephritis
B. Uncomplicated
Question #1
C. Complicated
D. I don’t know, ID consult please!
 Culture

Midstream Clean
Catheterization
Catch

Suprapubic
Bladder Aspiration
Bacterial Etiology (Uncomplicated)

E. Coli (80% - Klebsiella

90%) Pneumoniae

Enterococcus
Proteus Species
Species
Bacterial Etiology (Complicated)
E. Coli (< 50%)

Enterococcus Species

Klebsiella Pneumoniae

Enterobacter Species

Staphylococcus Species

Candida Species
 Bacterial Etiology (CA-UTI’s)

E. Coli (<30%) Klebsiella Species Serratia Species Citrobacter Species

Pseudomonas Morganella
Proteus mirabilis Providencia stuartii
aeruginosa morganii

Staphylococcus Enterococcus Coagulase negative

aureus species staphylococcus
  What bacteria is NOT commonly associated with
causing complicated UTI’s?
A. Eschieria coli
Question #2 B. Streptococcus mutans
C. Enterococcus faecalis
D. Enterobacter cloacae
  What bacteria is NOT commonly associated with causing
complicated UTI’s?
A. Eschieria coli
Question #2 B. Streptococcus mutans
C. Enterococcus faecalis
D. Enterobacter cloacae
Empiric Therapy
 Factors to consider:
 What allergies does the patient have?
 Does the patient have a history of recurrent infections or recent
treatment?
 If so, what culture results are there?
 Uncomplicated versus complicated infection?
 What’s the patient’s patient medical history?
 What is the patient's estimated renal function?
 Does the antibiotic cover the most likely bacteria?
 Does the antibiotic distribute to the site of the infection?
 What does the facilities antibiogram show about reported
susceptibilities?
Open Discussion

 What antimicrobial options are available for the treatment

of UTI’s?
Intravenous Antibiotic Empiric Therapy
Drug Dose Comment

Ceftriaxone 1-2 grams IV daily +/- gentamicin x 1 dose

Ciprofloxacin 400 mg IV every 12 hours

Levofloxacin 750 mg IV daily

Gentamicin 5 mg/kg IV once +/- ampicillin 1-2 g IV every

4-6 hours
 Culture and susceptibility data
for the local institution

Antibiogram Updated yearly

Helps guide empiric therapy

 Example: Antibiogram
Gram-negative # of isolates Gentamicin Cefazolin Ceftriaxone Ciprofloxacin Ampicillin Amp/ Amox/Clav Nitrofurantoin SMX/
Aerobes Sul TMP

Citrobacter freundii 50 83     93       100 80

Enterobacter aerogenes 34 100     97       6 94

Enterobacter cloacae 126 93     94       20 90

Escherichia coli 1046 91 78 89 72 52 57 77 96 76

Klebsiella oxytoca 101 97 53 91 97   59 86 97 93
Klebsiella pneumoniae 364 96 91 92 94   80 88 41 88

Morganella morganii 44 89   83 86   7     86

Proteus mirabilis 178 88 92 95 75 85 90 96   76

Pseudomonas 354 83     83          
aeruginosa

Serratia marcescens 73 96     71       0 78

Stenotrophomonas 58                 100
maltophilia
 Example: Antibiogram
Gram positive # of Ampicillin Gentamicin Gentamicin Linezolid Nafcillin Nitrofurantoin SMX/TMP Vancomycin
aerobes isolates Synergy

Enterococcus 406 100   69 99   100   96

faecalis

Enterococcus 111 22   64 98   67   39
faceium

Methicillin- 340   99 69 99 100 100 100 100

sensitive S. aureus

Methicillin- 255   94   100 0 100 98 100

resistant S. Aureus

Staphylococcus 480   77   100 39 100 60 100

coagulase-negative

Staphylococcus 197   69   100 24 100 51 100

epidermis
  Based on the example antibiogram, what empiric antibiotic
therapy would be most appropriate?
a. Ampicillin/sulbactam
b. Sulfamethoxazole/trimethoprim
c. Ampicillin plus gentamicin
Question #4 d. Ciprofloxacin
  Based on the example antibiogram, what empiric antibiotic
therapy would be most appropriate?
a. Ampicillin/sulbactam
b. Sulfamethoxazole/trimethoprim
c. Ampicillin plus gentamicin
Question #4 d. Ciprofloxacin
Patient Case
 On day 3, the patient reports feeling better, has not had any nausea or vomiting in
24 hours, and has been able to tolerate other medications orally. The following
urine culture has resulted:

Result: Enterococcus
Facealis
Ampicillin S
Daptomycin S
Linezolid S
Nitrofurantoin S
Vancomycin S
Question #5

 Which of the following antibiotic regimens would be most appropriate

based on the urine culture results and the patient’s infection?
A. Linezolid 600 mg PO every 12 hours
B. Ampicillin 2 grams IVPB every 4 hours
C. Vancomycin 250 mg PO every 6 hours
D. Nitrofurantoin monohydrate100 mg PO twice daily
Question #5

 Which of the following antibiotic regimens would be most appropriate

based on the urine culture results and the patient’s infection?
A. Linezolid 600 mg PO every 12 hours
B. Ampicillin 2 grams IVPB every 4 hours
C. Vancomycin 250 mg PO every 6 hours
D. Nitrofurantoin monohydrate100 mg PO twice daily
Treatment Duration

Infection Drug Duration

Uncomplicated Nitrofurantoin 100 mg PO 5 days
twice daily
SMX/TMP 1 DS PO twice 3 days
daily
Fosfomycin PO 3 grams 1 day
Fluoroquinolone 3 days
Beta-lactam based regimen 3-7 days
Treatment Duration (continued)

Infection Drug Duration

Complicated/ Ciprofloxacin 400 mg IV every 8-12 7 days
pyelonephritis hours or 500 mg PO every 12 hours
Levofloxacin PO 750 mg daily 5 days
SMX/TMP 1 DS PO twice daily 14 days
Beta-lactam based regimen 10 -14 days
  The physician accepts your recommendation to start
nitrofurantoin 100 mg PO twice daily. They ask you how
many days should the patient be treated with nitrofurantoin.
What would be the most appropriate recommendation?
a. 7 days
Question #6 b. 3 days
c. 10 days
d. 5 days
  The physician accepts your recommendation to start
nitrofurantoin 100 mg PO twice daily. They ask you how
many days should the patient be treated with nitrofurantoin.
What would be the most appropriate recommendation?
a. 7 days
Question #6 b. 3 days
c. 10 days
d. 5 days
Questions?
An Overview of Urinary Tract
Infections and Pyelonephritis
Nicholas Corbin, PharmD
Franciscan Health – Indianapolis
References

 Bates BN. Interpretation of Urinalysis and Urine Culture for UTI Treatment. US Pharm.
2013; 38(11):65-8.  
 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 the European Society for Microbiology and
Infectious Diseases. Clinical Infectious Diseases. 2011; 55(5): 103-20.
DOI:10.1093/cid/cidq257. 
 Fernandez 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 eds. New York City, NY. McGraw Hill, 2020.