UTI

Classification of UTI

Uncomplicated UTI:

• Localized to bladder → signs and symptoms are localized to bladder

Complicated UTI:

• Infections extending beyond the bladder

  • Systemic signs/symptoms 

  • Pyelonephritis 

  • Catherizaton 

• Systemic Signs/Symptoms include:

  • Fever

  • Chills/Rigors/Hypotension 

  • Flank Pain

  • Costovertebral angle tenderness

UTI Pathogens…

1. Uncomplicated UTI/cystitis → E.coli

2. Complicated UTI → E.coli

Both: gram-negatives 

• Other Enterobacterales (KEEPs), Enterococcus species 

• Pseudomonas aeruginosa in critically ill patients 

Local vs Systemic UTI Sx…

Local Urinary Signs and Symptoms…

• Dysuria 

• Urinary frequency 

• Urgency 

• Suprapubic pain 

Systemic Urinary Signs and Symptoms…

• Fever

• Mental status changes (confusion, lethargy)

Urinalysis and UTI…

1. Elevated WBC in urine = UTI present 

   1. If absent of WBC = means NO uti 

   2. Not reliable for catheterized patients 

2. Leukocyte esterase 

   1. Surrogate for presence of WBC

3. Nitrites 

   1. Metabolic byproduct of gram-negative bacteria 

Urine Culture

used to guide antibiotic therapy 

→ MUST BE TAKEN BEFORE initiation of antibiotics 

• Identifies: pathogen, quantity, susceptibilities 

Who do we treat for asymptomatic bacteriuria?

1. Pregnany women: reduces the risk of pyelonephritis

2. Patients undergoing traumatic genitourinary procedures associated with mucosal bleeding

Uncomplicated UTI (Cystitis)...first line treatments

→ first line treatments: Nitrofurantoin, Fosfomycin

TMP/SMX (Bactrim) for uncomplicated UTIs…

• Duration = 3 days 

• Major DD with warfarin 

• Lower risk of resistant bacteria being resistant to other drug classes

Nitrofurantoin (Macrobid)

→ only used for uncomplicated UTIs

Duration = 5 days

• Do NOT use in Pyelonephritis 

• Do NOT use if CrCl < 30 mL/min

Fosfomycin (Monurol)

Duration = 1 dose ONLY

• Oral form not indicated for pyelonephritis  

uAcute Cystitis IDSA guideline recs

(uncomplicated UTIs)

1. Nitrofurantoin 5 days 

2. Bactrim 3 days

3. Fosfomycin single dose

Other agents…

• B-lactam (oral) 5-7 duration if top three cannot be used

  • amox/clav, cefdinir, cephalexin

• Fluoroquinolones 3 day duration (last line)

  • Ciprofloxacin, levofloxacin

IDSA recs for complicated UTI: OUTPATIENT…

• Outpatient and FQ resistance < 10%

  • Ciprofloxacin for 7 days 

  • Levofloxacin for 5 days 

• Outpatient AND bactrim susceptible

  • Bactrim (TMP/SMX) for 14 days

IDSA recs for complicated UTI: INPATIENT…

• Empiric IV…7 day course

  • 3rd/4th gen Cephalosporin (ceftriaxone, cefepime)

  • pip/tazo

  • Carbapenem

  • Fluoroquinolone 

  • Aminoglycoside

Durations of Treatment for Complicated UTIs

• Levoflox - 5 days IV/PO

• Ciprofllox - 7 days IV/PO

• IV B-lactam - 7 days 

• Initial IV Tx - 7 days 

• TMP/SMX - 7 days IV/PO

Duration of Catheter Associated UTI TX…

• Prompt clinical response = 7 days 

• Delated clinical response = 10-14 days 

• NOT severely ill = Levo for 5 days

• Women < 65, no upper UTI symptoms, catheter has been removed = 3 days

Catheter Associated UTI Symptoms

systemic signs/symptoms 

• fever/rigors

• Altered mental status 

• Flank pain 

Remove catherer if possible and replace, need to culture urine from NEW catherer