Urinary Tract Infection


Article Author:
Michael Bono


Article Editor:
Wanda Reygaert


Editors In Chief:
Zina Clark
Barbara Simmons


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Frank Smeeks
Kristina Soman-Faulkner
Trevor Nezwek
Radia Jamil
Patrick Le
Sobhan Daneshfar
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
11/15/2018 10:32:26 PM

Introduction

Uncomplicated urinary tract infection (UTI) is a bacterial infection of the bladder and associated structures. These are patients with no structural abnormality and no comorbidities, such as diabetes, immunocompromised, or pregnant. Uncomplicated UTI is also known as cystitis or lower UTI. Forty percent of women in the United States will develop a UTI during their lifetime, making it one of the most common infections in women. UTI is uncommon in circumcised males, and by definition, any male UTI is considered complicated. Many cases of uncomplicated UTI will resolve spontaneously, without treatment, but many patients seek treatment for symptoms. Treatment is aimed at preventing spread to the kidneys or developing into upper tract disease/pyelonephritis, which can cause the destruction of the delicate structures in the nephrons and lead to hypertension.[1][2][3]

Etiology

Pathogenic bacteria ascend from the perineum, causing UTI. Women have shorter urethras than men and therefore are more susceptible to UTI. Very few uncomplicated UTIs are caused by blood-borne bacteria. Escherichia coli is the most common organism in uncomplicated UTI by a large margin.[4]

Epidemiology

Urinary tract infections are very frequent bacterial infection in women. They usually occur between the ages of 16 and 35 years, with 10% of women getting an infection yearly and more than 40% to 60% having an infection at least once in their lives. Recurrences are common, with nearly half getting a second infection within a year. Urinary tract infections occur four times more frequently in females than males.[5][6]

Pathophysiology

An uncomplicated UTI usually only involves the bladder. When the bacteria invade the bladder mucosal wall, cystitis is produced. The majority of organisms causing a UTI are enteric coliforms that usually inhabit the periurethral vaginal introitus. These organisms ascend into the bladder and cause a UTI. Sexual intercourse is a common cause of a UTI as it promotes the migration of bacteria into the bladder. People who frequently void and empty the bladder have a much lower risk of a UTI.[7]

History and Physical

Symptoms of uncomplicated UTI are a pain on urination (dysuria), frequent urination (frequency), inability to start the urine stream (hesitation), sudden onset of the need to urinate (urgency), and blood in the urine (hematuria). Usually, patients with uncomplicated UTI do not have fever, chills, nausea, vomiting, or back pain, which are signs of kidney involvement or upper tract disease/pyelonephritis. Clinical symptoms can overlap, and in some cases, it is hard to distinguish uncomplicated UTI from a kidney infection. When in doubt, treat aggressively for possible upper renal tract disease. Diagnosis is a combination of signs, symptoms, and urinalysis. Be careful of literature that is based on the results of urinalysis of asymptomatic patients.

Evaluation

A good, clean, urinalysis (UA) specimen is vital to the workup. A clean-catch specimen in nonobese women is preferred. Most obese women cannot give a clean specimen, and epithelial cells in the UA means the urine sample was exposed to the genital surface and did not come directly out of the urethra. Get a clean sample, with very few epithelial cells. In-and-out catheterization of the bladder will cause UTI in uninfected women 1% of the time. Men should start the urine stream to clean the urethra and then obtain a midstream sample. Urine should be sent to the lab immediately or refrigerated because bacteria grow rapidly when a sample is left at room temperature, causing an overestimate of the infection's severity.[8][9]

Do not base the diagnosis upon visual inspection of the urine. Cloudy urine can be aseptic; the cloudiness can come from protein in the sample, not necessarily infection. Crystal clear urine can be grossly infected. All urines undergo dipstick testing, which can be done at the bedside. Helpful values are pH, nitrites, leukocyte esterase, and blood. Remember that in patients with symptoms of UTI, a negative dipstick does not rule out UTI, but positive findings can help make the diagnosis. Look for the presence of bacteria and/or white blood cells (WBC) in the urine.

Normal urine pH is slightly acidic, with usual values of 6.0 to 7.5, but the normal range is 4.5 to 8.0. A urine pH of 8.5 or 9.0 is indicative of a urea-splitting organism, such as Proteus, Klebsiella, or Ureaplasma urealyticum; therefore, an asymptomatic patient with a high pH means UTI regardless of the other urine test results. Alkaline pH also can signify struvite kidney stones, which are also known as “infection stones.”

The most accurate dipstick test is the nitrite test because bacteria must be present in the urine to convert nitrates to nitrites. This takes 6 hours. This is why urologists request the first-morning urine, particularly in males. The specificity of this test is greater than 90%. This is direct confirmation of bacteria in the urine, which is UTI by definition in patients with symptoms. Several bacteria do not convert the nitrates to nitrites, but those are usually involved in complicated UTIs, such as those involving Enterococcus, Pseudomonas, and Acinetobacter.

Leukocyte esterase (LE) identifies the presence of WBCs in the urine. The WBCs release the LE, presumably in response to bacteria in the urine. This is why LE is a subsequent test with a specificity of only 55% for UTI. LE is good at detecting WBCs in the urine, but WBCs can be in the bladder for other reasons, like inflammatory disorders.

Hematuria can be helpful because bacterial infection of the transitional cell lining of the bladder can cause bleeding. This helps distinguish UTI from vaginitis and urethritis which do not cause blood in the urine.

In many labs, the presence of nitrites or leukocyte esterase will automatically trigger a microscopic evaluation of the urine for bacteria, WBCs, and RBCs. On microscopy, there should be no bacteria in uninfected urine, so any bacteria on a gram-stained urine under microscopy is highly correlated to UTI. A good urine sample with greater than 5 to 10 WBC/HPF is abnormal and highly suggestive of UTI in symptomatic patients.

Urine cultures are not needed in uncomplicated UTI. Urine should be cultured in all men and patients with diabetes mellitus, who are immunosuppressed, and women who are pregnant. Classic teaching on urine culture sets the gold standard for infected urine at greater than 10 colony forming units (CFU). Recent literature states that a patient who presents with symptoms and greater than 10 CFU is diagnostic of infection. Urine cultures rarely help in the emergency department, except with recurrent UTI.

Treatment / Management

Treatment has varied historically from 3 days to 6 weeks. There are excellent rates with “mini-dose therapy” which involves three days of treatment. E. coli resistance to common antimicrobials varies in different areas of the country, and if the resistance rate is greater than 50% choose another drug.

Trimethoprim/Sulfamethoxazole for 3 days is good mini-dose therapy, but resistance rates are high in many areas. First generation cephalosporins are good choices for mini-dose therapy. Nitrofurantoin is a good choice for uncomplicated UTI, but it is bacteriostatic, not bacteriocidal, and must be used for 5 to 7 days. Fluoroquinolones have high resistance but are a favorite of urologists for some reason. Recent precautions from the FDA about fluoroquinolone side effects should be heeded.[10][11][12]

Differential Diagnosis

  • Pyelonephritis
  • Renal stone
  • Vaginitis
  • PID
  • Herpes simplex

Pearls and Other Issues

Although there is no proof of prevention, women should urinate after sexual intercourse because bacteria in the bladder can increase by ten-fold after intercourse. After urination, women should wipe from front to back, not from the anal area forward, which seems to drag pathogenic organisms nearer to the urethra. Vigorous urine flow is helpful to prevention.

Enhancing Healthcare Team Outcomes

UTI is best managed in a multidisciplinary fashion, and besides physicians, most nurses will encounter a patient with a UTI. The key to preventing recurrences is the education of the patient. Once a UTI has been diagnosed the patient should drink more fluids. Sexually active women should try to void right after sexual intercourse as this can help flush the bacteria out of the bladder. Some women with recurrent UTIs may benefit from prophylactic use of antibiotics. Several other non-medical remedies may help some women with UTI. Anecdotal reports indicate that the use of cranberry juice and probiotics may help reduce the severity and frequency of UTI in some women.[13][14] (Level V)

Outcomes

The majority of women with a UTI have an excellent outcome. Following treatment with an antibiotic, the duration of symptoms is 2-4 days. Unfortunately, nearly 30% of women will have a recurrence of the infection. Morbidity is usually seen in older debilitated patients, those with renal calculi and in patients. Other factors linked to recurrence include the presence of diabetes, underlying malignancy, chemotherapy and chronic catheterization of the bladder. The mortality after a UTI is close to zero, but the infection does have a significant impact on finance. Women often have to miss work, see the physician and purchase the antibiotic. [15][16](Level V)


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Urinary Tract Infection - Questions

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Of the following, which drug is ideal for treating recurrent urinary tract infections?



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What bacteria is the most common cause of urinary tract infections?



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Which of the following is most commonly used to treat an uncomplicated urinary tract infection?



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How many colonies are usually required in a clean catch specimen to make a diagnosis of a urinary tract infection?



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Which of the following imaging studies is required in patients with an uncomplicated urinary tract infection?



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What is the most common organism to cause a urinary tract infection in a 17-year-old?



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A woman presents with dysuria and lower abdominal pain. It is suspected that she may have a urinary tract infection. What is the best method of urine collection?



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When a urinary tract infection is present, which of the following is true with respect to urinalysis?



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Which organism most commonly causes urinary tract infections?



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Which of the following statements regarding urinary tract infections is false?



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Which of the following statements about urinary tract infections is not true?



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When the urine has a positive nitrite test, which of the following organisms is most likely present?



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When a urinary tract infection is present, which of the following is most likely true?



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What is the most common risk factor for urinary tract infection in females?



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Which of the following is not recommended when managing recurrent urinary tract infections in females?



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What is the most common pathogen that causes simple urinary tract infections in females?



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What anatomical difference is responsible for the low incidence of urinary tract infections in men?



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Which condition is least likely to be associated with urinary tract infections?



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Which of the following urinalysis results necessitates antibiotic treatment in an asymptomatic 71-year-old female?



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Besides the recommendation of antibiotic therapy, what additional instructions should be given to a patient with the new onset of a urinary tract infection and a long history of hypertension on beta blockers whose urinalysis shows a pH of 6.8, a specific gravity of 1.030 and 3 RBCs per high power field?



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What do positive nitrites indicate on urinalysis?



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What is the most common cause of community-acquired urinary tract infection?



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Which of the following organisms is most likely to be the cause of a urinary tract infection in an immunocompromised host?



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Which of the following antibiotics can be used for an uncomplicated urinary tract infection in an infant?



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Which of the following can cause constant dribbling in a young child?



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Which of the following is not a risk factor for urinary tract infection in elderly patients?



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Which of the following is the most common cause of urinary tract infection?



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Select the appropriate treatment for an uncomplicated urinary tract infection in an elderly female.



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Which of the following is appropriate treatment of simple uncomplicated urinary tract infection?



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What is the most common cause of urinary tract infections?



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A 5-year-old female was successfully toilet trained 18 months ago. She had developed daytime enuresis one week ago. The parents report no new stress, fevers, or other symptoms. Physical exam is normal. What is the next best step in this patient's management?



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Select the condition that does not increase the incidence of urinary tract infection.



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Which of the following is true of urinary tract infections?



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Which of the following abnormality leading to urinary tract infections in young US children is atypical?



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Which of the following is the best choice for the treatment of a urinary tract infection in the third trimester of pregnancy?



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The urine dipstick nitrate test may be positive with which of the following types of infection?



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Which of the following is the most common cause of urinary tract infections in children?



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On postoperative day 4, an otherwise healthy 45-year-old female recovering from a colon resection is noted to have a fever of 38.8°C (101.6°F). Which is the most common postoperative nosocomial infection?



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Which is false regarding urinary tract infection (UTI)?



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Which is true regarding diagnosis of urinary tract infection (UTI) in women?



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Which signs and symptoms in the elderly may suggest a urinary tract infection?



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Which of the following is not a risk factor for urinary tract infection?



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Which laboratory test does NOT suggest an urinary tract infection?



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Which of the following is true regarding urinary tract infections in the elderly?



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Which of the following is inappropriate education for the woman with a urinary tract infection?



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A 4-week old female has a urinary tract infection. Select the most likely causative organism.



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Which antibiotic is the most appropriate treatment for a simple urinary tract infection in an adult female?



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Which substance can be found in the urine of a patient with a urinary tract infection?



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What is the predominant organism that causes a urinary tract infection?



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E. coli is by far the most common cause of urinary sepsis in the elderly and nursing home patient population. But what are the next most common organisms, in order of frequency?



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What is the annual rate of pediatric urinary tract infection?



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In which pediatric age group are boys more likely to develop urinary tract infections than girls?



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How sensitive and specific are the combined urinary dipstick readings for leukocyte esterase and nitrites in correctly identifying a pediatric urinary tract infection?



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A female is in the emergency department complaining of a urinary tract infection (UTI). On obtaining her history, what signs and symptoms may be present? Select all that apply.



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An adult female patient is being discharged to home following treatment of a urinary tract infection in the emergency department. What instructions will the registered nurse reinforce during discharge teaching? Select all that apply.



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Urinary Tract Infection - References

References

Five-day nitrofurantoin is better than single-dose fosfomycin at resolving UTI symptoms. Drug and therapeutics bulletin. 2018 Oct 8     [PubMed]
Long B,Koyfman A, The Emergency Department Diagnosis and Management of Urinary Tract Infection. Emergency medicine clinics of North America. 2018 Nov     [PubMed]
Tang M,Quanstrom K,Jin C,Suskind AM, Recurrent Urinary Tract Infections are associated with Frailty in Older Adults. Urology. 2018 Oct 5     [PubMed]
Yamaji R,Friedman CR,Rubin J,Suh J,Thys E,McDermott P,Hung-Fan M,Riley LW, A Population-Based Surveillance Study of Shared Genotypes of Escherichia coli Isolates from Retail Meat and Suspected Cases of Urinary Tract Infections. mSphere. 2018 Aug 15     [PubMed]
Sakamoto S,Miyazawa K,Yasui T,Iguchi T,Fujita M,Nishimatsu H,Masaki T,Hasegawa T,Hibi H,Arakawa T,Ando R,Kato Y,Ishito N,Yamaguchi S,Takazawa R,Tsujihata M,Taguchi M,Akakura K,Hata A,Ichikawa T, Chronological changes in epidemiological characteristics of lower urinary tract urolithiasis in Japan. International journal of urology : official journal of the Japanese Urological Association. 2018 Oct 11     [PubMed]
Alperin M,Burnett L,Lukacz E,Brubaker L, The mysteries of menopause and urogynecologic health: clinical and scientific gaps. Menopause (New York, N.Y.). 2018 Oct 8     [PubMed]
Maharjan G,Khadka P,Siddhi Shilpakar G,Chapagain G,Dhungana GR, Catheter-Associated Urinary Tract Infection and Obstinate Biofilm Producers. The Canadian journal of infectious diseases     [PubMed]
Richards KA,Cesario S,Best SL,Deeren SM,Bushman W,Safdar N, Reflex urine culture testing in an ambulatory urology clinic: Implications for antibiotic stewardship in urology. International journal of urology : official journal of the Japanese Urological Association. 2018 Sep 16     [PubMed]
Araujo da Silva AR,Marques AF,Biscaia di Biase C,Zingg W,Dramowski A,Sharland M, Interventions to prevent urinary catheter-associated infections in children and neonates: a systematic review. Journal of pediatric urology. 2018 Jul 21     [PubMed]
O'Grady MC,Barry L,Corcoran GD,Hooton C,Sleator RD,Lucey B, Empirical treatment of urinary tract infections: how rational are our guidelines? The Journal of antimicrobial chemotherapy. 2018 Oct 8     [PubMed]
Ditkoff EL,Theofanides M,Aisen CM,Kowalik CG,Cohn JA,Sui W,Rutman M,Adam RA,Dmochowski RR,Cooper KL, Assessment of practices in screening and treating women with bacteriuria. The Canadian journal of urology. 2018 Oct     [PubMed]
Ganzeboom KMJ,Uijen AA,Teunissen DTAM,Assendelft WJJ,Peters HJG,Hautvast JLA,Van Jaarsveld CHM, Urine cultures and antibiotics for urinary tract infections in Dutch general practice. Primary health care research     [PubMed]
Li F,Song M,Xu L,Deng B,Zhu S,Li X, Risk factors for catheter-associated urinary tract infection among hospitalized patients: a systematic review and meta-analysis of observational studies. Journal of advanced nursing. 2018 Sep 26     [PubMed]
Lengetti E,Kronk R,Ulmer KW,Wilf K,Murphy D,Rosanelli M,Taylor A, An innovative approach to educating nurses to clinical competence: A randomized controlled trial. Nurse education in practice. 2018 Sep 8     [PubMed]
Hooton TM,Vecchio M,Iroz A,Tack I,Dornic Q,Seksek I,Lotan Y, Effect of Increased Daily Water Intake in Premenopausal Women With Recurrent Urinary Tract Infections: A Randomized Clinical Trial. JAMA internal medicine. 2018 Oct 1     [PubMed]
Liu Y,Xiao D,Shi XH, Urinary tract infection control in intensive care patients. Medicine. 2018 Sep     [PubMed]

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