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Information ⬇

Author(s): Carolyn Hemsley and Claire van Nispen tot Pannerden

Consider urinary tract infection when the patient has symptoms directly referable to the urinary tract:

In the differential diagnosis of non-specific presentations:

Point-of-care urinary testing by urinary dipstick in those with symptoms suggestive of UTI, assessing for pyuria, is sensitive and specific in the non-immunosuppressed population, and can support or exclude the diagnosis at the patient's bedside.

Priorities ⬆ ⬇

  1. Determine whether the infection is uncomplicated or complicated (Table 80.1) by clinical assessment (Table 80.2), review of previous microbiology results and investigation (Tables 80.3 and 80.4). This will guide the need for further investigation, the choice of empirical antibiotic therapy, the length of treatment, and the requirement for follow-up.

    It is not always apparent at the time of acute presentation whether the infection is complicated or not, but this may become obvious later in the course of treatment.

    • Uncomplicated – simple lower urinary tract infection in an otherwise healthy, non-pregnant woman.
    • Complicated – UTI in the presence of an underlying condition that increases the risk of infection or the chance of failing therapy (Table 80.1).
  2. If the patient is febrile or has significant systemic upset send peripheral blood as well as urine for culture before starting appropriate empirical antibiotics (Tables 80.5 and 80.6).
    • The choice of agent depends on local epidemiology and resistance rates of common urinary pathogens and is usually indicated by local guidelines.
    • Consider recent antibiotic history, especially if considering treatment failure.
    • Consider recent microbiological culture results if available.
    • Mode of delivery of the antibiotic (intravenous versus oral) will depend on the acuity of the illness and ability of patient to tolerate oral antibiotics.
    • Review antibiotic choice in pregnancy.
  3. If suspected uncomplicated urinary tract infection (i.e. only lower urinary tract symptoms in a young woman with no features of systemic upset and no previous antimicrobial therapy) then treatment with empirical antibiotic without the need for urine culture is appropriate (Table 80.5). The patient should be advised to return if treatment fails to resolve symptoms, at which point urinary culture is indicated to guide further correct antimicrobial selection. Uncomplicated UTI or pyelonephritis in a young woman with complete symptom resolution does not need follow-up.
  4. Relieve acute urinary retention. UTI is a common precipitant for acute on chronic retention in older men with prostatic enlargement and partial bladder outflow obstruction.
    • Catheterize if in acute urinary retention.
    • Unblock or replace blocked urinary catheters with appropriate antibiotic cover if long-term catheter in situ.
  5. If there is an associated acute kidney injury, manage this along standard lines (Chapter 25).
    • Ensure appropriate fluid management including input/output chart.
    • Arrange ultrasonography of the kidneys and urinary tract to exclude obstruction requiring intervention.
  6. Consider the need for urinary tract imaging (Table 80.4).

Further Management ⬆ ⬇

  1. Review urinary culture results and change antimicrobial therapy as guided by susceptibility data. Urine culture results will be available at 24–48h. Antibiotic course length depends on the clinical picture and whether it is uncomplicated or complicated UTI (Tables 80.1, 80.5 and 80.6).
  2. If persisting fever at 72h or ongoing symptoms or sepsis despite antimicrobial therapy:
    • Consider if wrong diagnosis. If dysuria, consider perineal candidiasis, vaginitis, urethritis or sexually transmitted infection.
    • If suprapubic or abdominal discomfort, review the need for abdominal imaging to exclude an alternative diagnosis, for example salpingitis, diverticulitis, appendicitis. Is the patient on the appropriate antimicrobial therapy?
    • Review microbiology results and discuss antibiotic therapy with microbiologist or infection specialist.
    • Has renal tract imaging been performed (Table 80.4)? Consider the presence of underlying complete or partial upper renal tract obstruction needing decompression. Consider the presence of a collection requiring drainage (radiologically guided or surgical).
  3. Decide if you should refer to a urologist, either acutely or for follow-up (Table 80.7):
    • Decompression of upper renal tract if ureteric obstruction is present, for example by nephrostomy.
    • Drainage of perinephric collections or renal abscess.
    • Men with recurrent cystitis should be evaluated for prostatitis.
  4. Change long-term urinary catheters. In catheter-associated urinary tract infections (CAUTIs), urinary catheter colonization with bacteria is inevitable and hard to eradicate. Replacement of urinary catheters whilst on antibiotic treatment is advisable.
  5. Presentation with recurrent symptoms within a few weeks of treatment should have further evaluation for complicated UTI:
    • Have they had renal/urinary tract imaging?
    • Repeat a urine culture for resistant bacteria.
    • Consider performing urodynamics. Is there bladder dysfunction or incomplete emptying?
    • Consider referral to urologist for cystoscopy.

Further Reading ⬆

Hooton TM (2012) Uncomplicated urinary tract infection. N Engl J Med 366, 1028–1037.

Shaeffer AJ, Nicolle LE (2016) Urinary tract infections in older men. N Engl J Med 374, 562–571.