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URINARY TRACT INFECTION
Amimi Osayande, M.D.
Department of Family & Community Medicine
History
Onset of symptoms
Nature of symptoms (pain intensity, timing, and localization)
Abnormality in urine pattern, color – frequency, nocturia, incontinence, observed hematuria
Associated symptoms - pelvic pain fever; chills, back pain, vaginal discharge
Last menstrual period in females
Sexual activity, type of contraception, symptoms in partner (if any)
History of prior urinary or gynecologic symptoms and infections
Other co morbid conditions
Allergies
Use of medications and other topical hygiene products
Risk Factors suggesting complicated UTI:
Functional or anatomic abnormality of the urinary tract
Indwelling urinary catheter
Recent urinary tract instrumentation
Pregnant women
Men
Elderly
Healthcare-associated infection
Recent antimicrobial use
Symptoms for more than seven days at presentation
Diabetes mellitus or other immunosuppression
History of childhood urinary tract infection
Physical exam
Vital signs and general appearance.
Must include an abdominal exam and assessment for costovertebral angle tenderness.
Diagnostic Testing
Urinalysis:
Recommend mid stream urine for better accuracy.
Leukocyte esterase: Marker for white blood cells and has a sensitivity of 75 percent for the detection of
UTI and is considered less sensitive than microscopy.
Pyuria: (3-5 WBC/HPF) has sensitivity of 96%, and a positive result for pyuria and/or bacteria is enough
evidence of infection in which case, treat patients empirically if symptomatic.
Sterile pyuria – Pyuria in the absence of bacteria is seen in non infectious urologic conditions like calculi
or infection with unusual organisms like C. trachomatis
Nitrites: A dipstick test that is positive for nitrite suggests a probable UTI, however, a negative test does
not rule out the diagnosis.
Urine cultures:
Cultures are not essential in selected young women when clear-cut signs and symptoms of acute dysuria
indicate a high probability of uncomplicated cystitis. When symptoms are present, a count of 103 colonyforming units (CFU) per mL of urine is generally diagnostic of infection.
Optional testing in complicated UTI:
Urine cytology: Bladder cancer complicating UTI.
Vaginal and Urethral smears: In cases of associated discharge
STD testing
© 2010 The University of Texas Southwestern Medical Center at Dallas
Urinary Tract Infection
The University of Texas Southwestern Medical Center at Dallas
Imaging studies –
- Ultrasound: Upper urinary tract pathology
- Plain film X-ray of Kidneys, Ureters and Bladder: Suspected stones
- Intravenous pyelogram: Recurrent UTI
- Voiding cystouretography: Chronic UTI’S (e.g. congenital bladder abnormalities)
- CT Scan/MRI
- In children, imaging (Renal USS or VCUG) is not routinely recommended except in the
following cases:
 Girls younger than 3 years of age with a first
 Boys of any age with a first UTI
 Children of any age with a febrile UTI
 Children with recurrent UTI (if they have not been imaged previously)
 First UTI in a child of any age with a family history of renal disease, abnormal voiding
pattern, poor growth, hypertension or abnormalities of the urinary tract
Differential Diagnoses:
Chlamydial or Gonococcal urethritis, Vaginitis, Atrophic vaginitis, interstitial cystitis, Renal calculi
Treatment:
Acute uncomplicated UTI in women.
3 day regimens of TMP-SMX or an oral Fluoroquinolone.
TMP-SMX: 160/800mg every 12 hrs should be considered the current standard therapy (SOR A, Level I).
Fluoroquinolones are more expensive than TMP-SMX and to postpone emergence of resistance to these
drugs, they are not recommended as initial empirical therapy except in communities with high rates of
resistance (i.e., 10%–20%) to TMP-SMX among uropathogens.
Levofloxacin: 250mg every 24 hrs
Ciprofloxacin: 100 – 250mg every 12 hrs
Other options:
Nitrofurantoin Monohydrate Macrocrystals: 100mg every 12 hrs x 5 days
Amoxicillin/Clavulanic acid: 500mg every 12 hrs x 7 days
Cefpodoxime Proxetil; 100mg every 12 hrs x 3-7 days
Acute uncomplicated Pyelonephritis
For young non pregnant women with normal urinary tracts 7 -14 days of Antibiotics (SOR A, Level I);
Mild – Moderate:
7 days (SOR B, Level I). Oral medications (SOR A, Level II).
Oral fluoroquinolones, (SOR A, Level II)
Levofloxacin: 500mg - 750 mg every 24 hrs (5 day regimen is enough due to potency)
Ciprofloxacin: 500mg every 12 hrs
OR,
If the organism is known to be susceptible,
TMP -SMX (SOR B, Level II): 160/800mg every 12 hrs
Known Gram positive bacteria:
Amoxicillin OR Amoxicillin/Clavulanic acid may be used alone (SOR B, Level III). 500 mg every 8
hours or 500-875 mg every 12 hours
Severe
Patients should be hospitalized (SOR A, Level II). Treat with a parenteral fluoroquinolone, an
aminoglycoside with or without Ampicillin, OR an extended-spectrum cephalosporin with or without
an aminoglycoside (SOR B, Level III).
Gram-positive cocci : Ampicillin/sulbactam with or without an aminoglycoside (SOR B, Level III).
Treat until patient is afebrile, then switch to oral medications to complete 14 days.
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Urinary Tract Infection
The University of Texas Southwestern Medical Center at Dallas
Complicated UTI in men and women
Mild-Moderate
Oral Fluoroquinolone for 10 -14 days, follow up on cultures and antibiotic sensitivities
Severe
Empiric Parenteral antibiotics until cultures and antimicrobial sensitivity return:
Penicillin or Cephalosporin with an aminoglycoside, Imipenem-cilastin, Aztreonem,
Ticarcillin/Clavulanate, Ceftriaxone (if organism is non enterococcal). Start oral medications –
Quinolone or TMP-SMX after patient is afebrile and complete for 10-21 days.
Cases in which screening, antibiotics are not indicated
1. Asymptomatic Bacteriuria in non-pregnant women
2. Urinary Catheter Associated Asymptomatic Bacteriuria
3. Asymptomatic Bacteriuria in Diabetes Mellitus
4. Asymptomatic Bacteriuria in Spinal Cord Injuries
5. Asymptomatic Bacteriuria in Older patients
Special populations:
1. Pregnancy:
Treat all urinary tract infections in pregnancy including asymptomatic UTI.
First Line Antibiotics in Pregnancy
 Macrodantin 100 mg every 6-8 hrs (avoid after 38 weeks)
 Macrobid 100 mg every 12 hrs (avoid after 38 weeks)
 Keflex (Cephalexin) 250 mg every 6 hrs
 Ceftin (Cefuroxime) 125-250 mg every 12 hrs
2. Children:
First episode of uncomplicated cystitis in older children (older than two years) who are afebrile
be treated for five to seven days.
Young children, male adolescents, and children with recurrent, febrile, or complicated cystitis
treat for 10 to 14 days.
 Amoxicillin 20-40 mg/kg/day divided every 8 hrs (First choice antibiotic in age <2
months)
 Amoxicillin-clavulanate (Augmentin)
 TMP-SMX - Dosing: 6-12 mg/kg TMP,30-60 mg/kg SMX every 12 hrs (Avoid under age
2 months)
 Second generation or Third Generation Cephalosporins
 Cefixime (Suprax) 8 mg/kg every 12 hrs
 Cefpodoxime (Vantin) 10 mg/kg every 12 hrs
 Cefprozil (Cefzil) 30 mg/kg every 12 hrs
 Cephalexin (Keflex) 50-100 mg/kg every 6 hrs
 Loracarbef (Lorabid) 15-30 mg/kg every 12 hrs
References
- American Family Physician. Evaluation of dysuria in adults. Vol. 65/No. 8(April 15, 2002).
http://www.aafp.org/afp/2002/0415/p1589.html.
- Warren, JW, Abrutyn, E, Hebel, JR, et al. Guidelines for antimicrobial treatment of
uncomplicated acute bacterial cystitis and acute pyelonephritis in women. Clin Infect Dis 1999;
29:745.
- Harrison’s principles of internal medicine, Vol 2, 16th edition, pgs 1718 - 1721
- UpToDate. Acute cystitis in women, Acute cystitis in men, Dysuria in adult women.
http://www.uptodate.com.
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Urinary Tract Infection
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The University of Texas Southwestern Medical Center at Dallas
Family Practice Notebook. Urinary tract infection, Acute Pyelonephritis in pregnancy.
http://www.fpnotebook.com.
Amimi Osayande, M.D.
Assistant Professor, Family & Community Medicine
Last Reviewed: February 2010
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