UTI

Urinary Tract Infection (UTI)

  • presence of microorganisms in the urinary tract that cannot be accounted for by contamination   Cystitis: inflamed bladder (lower UTI)   Pyelonephritis: inflamed kidneys and renal pelvis (upper UTI)   Prostatitis: inflamed prostate   Urethritis: inflamed urethra (usually associated w/ STI)

Risk Factors: -Structural / functional abnormalities

  • Obstruction (stone, benign prostatic hyperplasia, urethral strictures)
  • Instrumentation (indwelling catheter, surgery)
  • Neurologic (neurogenic bladder, spinal cord injuries)
  • Vesicoureteral reflux   -Female   -Pregnancy   -Sexual intercourse / use of spermicides or diaphragms   -Decrease in host defense mechanisms (uncontrolled diabetes, immunosuppression)   -Medications (anticholinergics, SGLT2i)

Sign/sxms

Uncomplicated Cystitis Drug Strength Duration First line
Nitrofurantoin 100mg PO BID x5days TMP/SMX 160/800mg PO BID x3 days Fosfomycin 3g PO X 1 dose Second line
Cipro 250mg PO BID x 3 days Levo 250mg PO QD x 3 days Augmentin 500mg PO X3-7 days Cefdinir 300mg PO X3-7 days Cefpodoxime Proxetil 100mg PO X3-7 days Cefaclor 250mg X3-7 days

Complicated Cystitis Drug Strength Duration TMP/SMX 160/800mg PO BID x3 days Cipro Levofloxacin 500mg PO 750mg PO x5-10 days B-Lactams X7-14 days Augmentin 500mg PO BID-TID Cefdinir 300mg PO BID Cefpodoxime Proxetil 200mg PO BID Cefaclor 500mg PO TID

Recurrent UTI -3+ UTIs w/in 1 year or 2+ w/in 6 months Reinfection Relapse

2 wks from last UTI < 2 wks from last UTI Caused by different organism than original isolate Caused by same organism originally isolated Prophylaxis may be indicated Usually indicates persistent infectious source

Postcoital Therapy Continuous Prophylaxis (3 – 12 months) Nitrofurantoin 100mg PO x 1 dose Nitrofurantoin 100mg PO QD TMP/SMX 40/200mg – 80/400mg PO x 1 dose TMP/SMX 40/200mg PO QD or TIW TMP 100mg PO x 1 dose TMP 100mg PO QD Cephalexin 250mg PO x 1 dose Cephalexin 125 – 250mg PO QD Fosfomycin 3g PO every 10 days -Cranberry -Probiotics -Hydration (~2.2L daiy) -Methenamine Hippurate/Methenamine Mandelate Uncomplicated Complicated Healthy, premenopausal, nonpreggers female All males No structural or funxtional of the urinary tract* structural or funxtional of the urinary tract* No conditions that may increase failure or serious outcomes† conditions that may increase failure or serious outcomes† Bugs: E Coli Klebsiella Pneumoniae Proteus spp. Staph saprophyticus Bugs: E Coli Klebsiella pneumonia Proteus spp. Enterobacter spp. Pseudomonas aeruginosa Enterococcus spp. Staphylococcus spp. Candida spp. *Obstruction (stone, benign prostatic hyperplasia, urethral strictures), instrumentation (indwelling catheter, surgery), neurologic (neurogenic bladder, spinal cord injury), vesicoureteral reflux

†Pregnancy, uncontrolled diabetes, immunosuppression, recurrent UTIs Dx: Urine Collection: Midstream clean-catch method (preferred), catheterization, suprapubic bladder aspiration (not routinely needed for uncomplicated cystits)

  1. Pyuria >10 WBC
  2. Leukocyte Esterace (detects pyuria; neutrophil granules)
  3. Nitrate (+): produced by some gram(-) (E coli, Proteus)

Uncomplicated Pyelonephritis Drug Strength Duration First line
Cipro 500mg PO BID x 7 days Levofloxacin 750mg PO QD x 5 days TMO/SMX 160/800mg PO BID x 14 days +/- Ceftriaxone or Aminoglycosdie 1g IV/IM

IV X 1 dose

X 24 hours Second Line B-lactams 10-14 days plus ceftriaxone or aminoglycoside IV x 24 hours Augmentin 500mg PO BID-TID Cefdinir 300mg PO BID Cefpodoxime Proxetil 200mg PO BID Cefaclor 500mg TID

Complicated Pyelonephritis -Continue IV therapy until clinically improved and afebrile for 24-48 hrs, then go to PO -Tx duration: 14 days Penicillin Cephalosporins Carbapenems Piperacillin/Tazobactam Ceftriaxone Cefepime Meropenem Ertapenem

Fungal UTI Bug: candida spp -Asymptomatic = no tx -Symptomatic =  Fluconazole 200mg (cystitis) or 200mg – 400mg (pyelonephritis) IV/PO daily x 14 days  Amphotericin B (AmB) deoxycholate 0.3-0.6mg/kg IV QD x 1-7 days  Flucytosine 25mg/kg PO QID x 7-14 days  AmB deoxycholate bladder irrigation (50mg/L) QD x 5 days (cystitis only)

Adjunctive therapy -Phenazopyridine Bacteriuria: presence of bacteria in the urine Significant bacteriuria

Asymptomatic bacteriuria: presence of 1 or more species of bacteria growing in the urine in the absence of signs or symptoms of UTI -Tx: Doesn’t require tx except in preggers and pt’s undergoing endoscopic urological procedures Symptomatic abacteriuria: presence of signs or symptoms of UTI in the absence of significant bacteriuria

Prostatitis Bugs: E coli, K pneumoniae & P mirabilis, enterococcus spp, nonfermenting GNRs, gram (+) organisms, atypical organisms. Tx: 4-6 weeks

No / Low Risk of STI Pathogens    Risk of STI Pathogens   Bacteremia or suspected prostatic abscess

Empiric therapy Ceftriaxone Piperacillin / tazobactam Ceftriaxone 500mg IM x 1 dose PLUS Doxycycline (Vibramycin) 100mg po BID Ceftriaxone Piperacillin / tazobactam Targeted therapy (also for chronic 4-6 weeks) Ciprofloxacin 500mg PO BID Levofloxacin 500mg PO QD TMP/SMX 160/800mg PO BID Doxycycline 100mg PO BID Tailored based on culture and susceptibility results Duration 2 weeks (can extend to 4 weeks if needed) 2 weeks 4 weeks

Special Pops

Catheter-Associated UTI (CAUTI) -obtain urine culture -initiate empiric therapy Tx: 7 days if prompt solution or 10-14 days if delayed response -Exceptions: -Levofloxacin 750mg PO QD x 5 days (not severely ill pts) -Fluoroquinolone or TMP/SMX x 3 days (healthy, premenopausal, nonpreggers if catheter removed)

Preggers -untreated can led to prematurity and low birth weight -routine cultures at initial and 28 week prenatal visits -avoid fluoroquinolones & tetracyclines Tx: 4-7 days -Beta-Lactams (preferred) -Nitrofurantoin 100mg PO BID -avoid at term -TMP/SMX 160/800mg PO BID -avoid in 3rd trimester -Fosfomycin 3g PO x 1 dose (less-preferred)