UTI 3

Question 1

What is the role of urine collection in UTIs?

Answer 1

• Urine can be collected by voiding, catheterization or suprapubic aspiration
  
  • These means are increasingly invasive but also increasingly accurate ways of obtaining urine
• The presumptive diagnosis of urinary tract infection is based on microscopic evaluation of the spun urine sediment
  
  • White cells, bacteria, along with red cells, are characteristic
  • When the urine from a healthy individual is cultured there is no growth
• If the urine does show bacterial colony-forming units of bacteria per milliliter, the colonies are counted to determine the number of bacteria that were in the urine
• Although most UTI show 105 cfu/ml, as few as 102 cfu/ml can be indicative of a UTI
• These same bacteria can be tested to determine their susceptibility to urinary and serum levels of antimicrobials used to treat infections

Question 2

What is the recommended treatment for individuals with uncomplicated UTIs?

Answer 2

• For symptoms of dysuria, frequency, and urgency:
  
  • indicates cystitis
  • medical management is recommended
• For additional symptoms of fever, chills, and flank pain:
  
  • indicates pyelonephritis
  • imagine is recommended before management
• If there is poor response to medical therapy, then imaging is recommended as well

Question 3

Highlight some of the major guidelines of treatment of UTIs.

Answer 3

• Infections that involve the bladder (cystitis) are treated by algorithms
• Cultures are not mandated for uncomplicated cystitis in a healthy woman
  
  • However, when the patient has had recent antibacterial therapy, presents with unresolved symptoms from a prior infectious episode, or has recurrent urinary tract infections, then cultures are required
• When a patient with recurrent urinary tract infection has different bacteria at long intervals, the infections are judged to be reinfections, i.e. coming from the outside each time
  
  • However, if the bacteria that cause recurrent infections are of the same type and occur at short intervals then the possibility of persistent focus within the urinary tract is likely

Question 4

What are the general guidelines for treatment of uncomplicated UTIs?

Answer 4

• The drugs used to treat infections are based on prior knowledge of presumed susceptibility of species
• Urinary tract infections are treated empirically initially and, if need be, alterations are based on culture and susceptibility results which are available 48 hours afterward
• Patients with recurrent urinary tract infections can be treated with low-dose prophylaxis, peri intercourse prophylaxis or intermittent therapy

Question 5

What are the general guidelines for treatment of complicated UTIs?

Answer 5

• Complicated urinary tract infections involve a host with an abnormal urinary tract and/or significant risk factors such as uncontrolled diabetes, AIDS, etc.
• Generally speaking, boys, children and men should be thought to have complicated urinary tract infections until proven otherwise
  
  • These infections cause not only cystitis and pyelonephritis but can lead to urosepsis, septic shock and death
• All these patients must have a thorough evaluation to include microscopy and urine culture but also include imaging studies, culture and susceptibility testing
  
  • However, it is mandatory to perform imaging studies to delineate abnormalities in the urinary tract and provide a road map for potential intervention
• Management of complicated urinary tract infections must be broad and intensive with therapy usually lasting for 7-21 days

Question 6

What are the specific medical treatment options for mild to moderate UTIs?

Answer 6

• Treatment of choice: Fluoroquinolones
• 7–14 days

Question 7

What are the specific medical management options for severe UTIs?

Answer 7

• Hospitalization with parenteral to oral therapy (7–21 days)
• Parenteral Rx until afebrile
• Fluoroquinolone
• Aminoglycoside ± ampicillin
• Extended-spectrum cephalosporin ± aminoglycoside
• If gram-positive pathogen: Ampicillin/sulbactam ± aminoglycoside

Question 8

What are the surgical interventions available for UTIs?

Answer 8

• Surgical intervention to drain the urinary tract or correct the problem may be necessary acutely if the patient is in extreme distress
• However, in many instances the infection process can be controlled and the underlying abnormalities can be treated in a more controlled environment

Question 9

What is the treatment algorithm for isolated, first case UTIs?

Answer 9

• Urinary analysis
• Optional culture
• If TMP/SMX resistance
  
  • use TMP/SMX or TMP for 3 days
• If TMP/SMX resistance >/= 10% to 20%
  
  • fluoroquinolones for 3 days or
  • nitrofurantoin for 7 days
  • fosfomycin - single dose therapy

Question 10

What is the treatment algorithm for treatment of UTIs that have received recent antibacterial therapy?

Answer 10

• Culture recommended
• Urinalysis recommended
• Fluoroquinolone for 3 days

Question 11

What is the algorithm for treatment of unresolved UTIs?

Answer 11

• Urinalysis recommended
• Culture recommended
• If prior treatment did not involve fluoroquinolone, treat with fluoroquinolone for 3 days
• If prior treatment involved fluoroquinolone, treat with parenteral pending susceptibility for 3 days

Question 12

What is the treatment algorithm for asymptomatic UTIs in pregnant women?

Answer 12

• Urinalysis recommended
• Culture recommended
• Penicillins and cephalosporins for 3-7 days for all trimesters
• Nitrofurantoin for 3-7 days for

Question 13

What is the algorithm for treating asymptomatic UTIs in elderly patients?

Answer 13

No treatment is indicated