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In theClinic

In the Clinic

Urinary Tract
Infection
Background page ITC3-2

Screening and Prevention page ITC3-3

Diagnosis and Evaluation page ITC3-5

Treatment and Management page ITC3-8

Practice Improvement page ITC3-13

Tool Kit page ITC3-14

Patient Information page ITC3-15

CME Questions page ITC3-16

Physician Writer The content of In the Clinic is drawn from the clinical information and education
Kalpana Gupta, MD, MPH resources of the American College of Physicians (ACP), including PIER (Physicians
Barbara Trautner, MD, PhD Information and Education Resource) and MKSAP (Medical Knowledge and Self-
Assessment Program). Annals of Internal Medicine editors develop In the Clinic
Affiliations: VA Boston from these primary sources in collaboration with the ACPs Medical Education
Healthcare System and and Publishing divisions and with the assistance of science writers and physician
Boston University School of writers. Editorial consultants from PIER and MKSAP provide expert review of the
Medicine, Boston, Massachu- content. Readers who are interested in these primary resources for more detail
setts; and Houston VA Health can consult http://pier.acponline.org, http://www.acponline.org/products_services/
Services Research Center of mksap/15/?pr31, and other resources referenced in each issue of In the Clinic.
Excellence at the Michael E.
DeBakey VA Medical Center CME Objective: To review current evidence for the background, screening and
and Baylor College of Medi- prevention, diagnosis and evaluation, and treatment and management of urinary
cine, Houston, Texas. tract infection.
Section Editors The information contained herein should never be used as a substitute for clinical
Deborah Cotton, MD, MPH judgment.
Darren Taichman, MD, PhD
Sankey Williams, MD 2012 American College of Physicians

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rinary tract infections (UTIs) are one of the most common infec-

U tions in both outpatient and inpatient settings. The term urinary


tract infection applies to a heterogeneous group of clinical syn-
dromes. Clinical entities encompassed by UTI include asymptomatic
bacteriuria, acute uncomplicated cystitis, recurrent cystitis, complicated
UTI, catheter-associated asymptomatic bacteriuria, catheter-associated
UTI (CAUTI), prostatitis, and pyelonephritis. Appropriate classification
of the UTI syndrome is crucial for optimal diagnosis and management.
The various categories of UTI are distinguished by the presence or absence
of symptoms referable to the urinary tract; the patients sex and comorbid
conditions; and genitourinary history, including the presence of stones or
stents. Because acute cystitis is the most common manifestation of UTI
and is most prevalent in women, most clinical research on UTI has been
done in adult women. Clinicians must carefully consider whether recom-
mendations derived from this evidence base are applicable to their patient
populations.

Background
What patient populations are at In contrast to the predominant
greatest risk for UTI? role of behavioral risk factors in
In the absence of known abnor- premenopausal women, mechani-
1. Hooton TM, Scholes
D, Hughes JP, et al. A
malities of the urinary tract, cal and physiologic factors that
prospective study of women are at higher risk for UTIs affect bladder emptying become
risk factors for symp-
tomatic urinary tract
than are men. Premenopausal important in postmenopausal
infection in young adult women are at especially high women (3). Diabetes may increase
women. N Engl J
Med. 1996;335:468- risk for acute cystitis; incidence is the risk for certain urinary tract
74. [PMID: 8672152]
2. Scholes D, Hooton
0.5 to 0.7 per person-year among disorders, including asymptomatic
TM, Roberts PL, Sta- sexually active women (1). Other bacteriuria, perirenal abscess,
pleton AE, Gupta K,
Stamm WE. Risk fac-
populations at risk for UTI include and emphysematous pyelonephri-
tors for recurrent uri- patients with voiding abnormalities tis (4). In men, risk for UTI is
nary tract infection in
young women. J In- related to diabetes, neurogenic primarily related to the prostatic
fect Dis. 2000;
182:1177-82.
bladder, spinal cord injury, preg- hypertrophy that occurs with ad-
[PMID: 10979915] nancy, prostatic hypertrophy, or vancing age. Temporary instru-
3. Hooton TM. Recurrent
urinary tract infection
urinary tract instrumentation. mentation of the urinary tract is
in women. Int J An- Bacteriuria, with or without ac- the major medical intervention
timicrob Agents.
2001;17:259-68. companying symptoms, is generally that increases the risk for UTI
[PMID: 11295405]
4. Hooton TM. Patho-
considered unavoidable in patients in hospitalized patients. Other
genesis of urinary requiring long-term indwelling comorbid conditions that increase
tract infections: an
update. J Antimicrob catheters. risk in both sexes include stones
Chemother. 2000;46 or foreign bodies, such as ureteral
Suppl 1:1-7. [PMID: What lifestyle factors or comorbid
11051617] stents, in the urinary system, and
5. Scholes D, Hawn TR, conditions are risk factors for diseases associated with a neuro-
Roberts PL, et al.
Family history and UTI? genic bladder.
risk of recurrent cysti- The strongest risk factors for acute
tis and pyelonephritis
in women. J Urol. uncomplicated cystitis in pre- A recent casecontrol study of 1261 fe-
2010;184:564-9. menopausal women include sexual male outpatients 18 to 49 years of age
[PMID: 20639019]
6. Nicolle LE, Bradley S, intercourse, use of spermicides, investigated the role of family history of
Colgan R, Rice JC,
pregnancy, and previous UTI. A UTI as a risk factor for recurrent UTI or
Schaeffer A, Hooton
TM; Infectious Dis- history of maternal UTI and age pyelonephritis. A history of any UTI in the
eases Society of mother conferred an increased risk for
America. Infectious at first UTI are also important risk
both recurrent UTI (odds ratio [OR], 2.5;
Diseases Society of
America guidelines
factors in this group, suggesting a 95% CI, 1.93.4) and pyelonephritis (OR,
for the diagnosis and genetic component to susceptibili- 3.3; CI, 2.44.5). Having a sister or daugh-
treatment of asymp-
tomatic bacteriuria in ty (2). Changes in vaginal micro- ter with UTI also increased the risk for re-
adults. Clin Infect Dis. bial flora in perimenopausal current UTI, with ORs ranging from 2.6 to
2005;40:643-54.
[PMID: 15714408] women may increase risk for UTI. 4.1 (5).

2012 American College of Physicians ITC3-2 In the Clinic Annals of Internal Medicine 6 March 2012

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Screening and
Is there a role for screening for recommended. Dipstick urinalysis is not Prevention
UTI or asymptomatic bacteriuria? considered sensitive enough to be a
In men and nonpregnant women, stand-alone test in pregnant women.
screening for asymptomatic bacteriuria
is generally not recommended because Screening for and treating asympto-
treatment does not improve clinical matic bacteriuria is also recommended
outcomes (6). Asymptomatic bacteri- in men who are about to have
uria does not lead to hypertension, transurethral resection of the prostate
chronic kidney disease, or decreased (TURP) or other urinary tract instru-
survival (7). Women with asympto- mentation resulting in mucosal bleed-
matic bacteriuria are at increased risk ing. Studies have shown that TURP
for symptomatic UTI, but treatment in bacteriuric men can precipitate
of asymptomatic bacteriuria does not bacteremia, with associated sepsis syn-
decrease the frequency of sympto- drome, and that antimicrobial treat-
matic infection (8). Asymptomatic ment of the bacteriuria can prevent
bacteriuria is a marker for poor overall these complications. The level of risk
health status in diabetic patients, associated with specific invasive uro-
7. Abrutyn E, Mossey J,
noncatheterized women living in logic procedures other than TURP in Berlin JA, et al. Does
patients with preexisting bacteriuria is asymptomatic bac-
retirement homes, and catheterized teriuria predict mor-
inpatients, but asymptomatic bac- not well-defined. However, the Infec- tality and does an-
timicrobial treatment
teriuria itself is not an independent tious Diseases Society of America reduce mortality in
risk factor for mortality. (IDSA) recommends that proce- elderly ambulatory
women? Ann Intern
dures anticipated to cause mucosal Med. 1994;120:827-
Abrutyn and coworkers prospectively fol- 33. [PMID: 7818631]
bleeding warrant preprocedure 8. Hooton TM, Scholes
lowed 1491 female residents of retirement screening by urine culture and D, Stapleton AE, et al.
communities. Clean-catch urine cultures treatment of asymptomatic bacteri-
A prospective study
of asymptomatic
were obtained at enrollment and every 6
uria before the procedure (6). Sim- bacteriuria in sexually
months. Women who had asymptomatic active young women.
bacteriuria were older and sicker than
ple catheter placement does not N Engl J Med. 2000;
343:992-7. [PMID:
those who had never had asymptomatic warrant screening. 11018165]
9. Patterson TF, Andriole
bacteriuria, but no relationship was found VT. Detection, signifi-
with mortality after adjusting for covari- Evidence is inadequate to support cance, and therapy of
ates, such as age at study entry. (7). definitive guidelines for the manage- bacteriuria in preg-
nancy. Update in the
ment of asymptomatic bacteriuria in managed health care
Asymptomatic bacteriuria during renal transplant recipients and neu- era. Infect Dis Clin
North Am. 1997;
pregnancy (4%7% of pregnant tropenic patients. Patients with renal 11:593-608. [PMID:
9378925]
women) is associated with a high transplants who have asymptomatic 10. Smaill F, Vazquez JC.
rate of progression to symptomatic bacteriuria are at higher risk for Antibiotics for
asymptomatic bac-
UTI, including pyelonephritis pyelonephritis, but whether pyelo- teriuria in pregnan-
cy. Cochrane Data-
(20%40% of pregnant women nephritis affects graft function is base Syst Rev.
with untreated asymptomatic bac- controversial (11, 12). The relation- 2007:CD000490.
[PMID: 17443502]
teriuria) (9). Asymptomatic bacteri- ship of asymptomatic bacteriuria to 11. Fiorante S, Fernn-
uria of pregnancy also is associated UTI and sepsis in patients with dez-Ruiz M, Lpez-
Medrano F, et al.
with low birthweight and preterm neutropenia is not well-studied. Bac- Acute graft
pyelonephritis in re-
labor, although a causative relation- teriuria diagnosed in neutropenic pa- nal transplant recipi-
ship has not been established. tients as part of a fever workup by ents: incidence, risk
factors and long-
definition is not asymptomatic. term outcome.
A meta-analysis of 14 studies involving Nephrol Dial Trans-
plant. 2011;26:1065-
2302 pregnant women found that anti- How can UTI be prevented? 73. [PMID: 20805254]
biotic treatment was effective at eradicat- Screening urine cultures should be 12. Fiorante S, Lpez-
Medrano F, Lizasoain
ing asymptomatic bacteriuria and at
obtained only in pregnant women M, et al. Systematic
preventing pyelonephritis (10). The num- screening and treat-
ber needed to treat to prevent 1 episode of and patients about to have an invasive ment of asympto-
matic bacteriuria in
pyelonephritis was 7 (CI, 68). Thus, 1-time urologic procedure. Infection should renal transplant re-
screening for asymptomatic bacteriuria be treated with directed antimicrobial cipients. Kidney Int.
2010;78:774-81.
by urine culture early in pregnancy is therapy based on culture results. [PMID: 20720526]

6 March 2012 Annals of Internal Medicine In the Clinic ITC3-3 2012 American College of Physicians

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Symptomatic UTI in women with patient-initiated therapy. In this
recurrent episodes can be prevented approach, women are provided with
with antimicrobial prophylaxis. The a course of appropriate antibiotics
criterion for the number of episodes to take at the onset of symptoms.
of UTI per year that justifies preven- The advantages of this approach
tive measures is arbitrary, and this include avoiding long-term use
decision should be individualized. of prophylactic antibiotics. The
13. Stapleton A, Latham Postcoital antibiotic prophylaxis has dosing frequency can be tailored to
RH, Johnson C,
Stamm WE. Post- been shown to be highly effective in an individual patients response,
coital antimicrobial preventing symptomatic recurrences with the goal of achieving UTI
prophylaxis for re-
current urinary tract in women with 3 to 4 episodes of prevention while minimizing an-
infection. A random-
UTI per year, particularly if these are tibiotic exposure. However, rates
ized, double-blind,
placebo-controlled temporally associated with coitus. are decreased only during the active
trial. JAMA. 1990;
264:703-6. [PMID:
prophylaxis period and return to
2197450] A randomized, double-blind, placebo- baseline levels after antimicrobials
14. Albert X, Huertas I,
Pereir II, Sanflix J,
controlled trial found that among women are discontinued.
Gosalbes V, Perrota with at least 2 culture-documented epi-
C. Antibiotics for
preventing recurrent sodes of UTI in the previous year, postcoital In postmenopausal women, daily
urinary tract infec- use of half of a single-strength tablet topical application of intravaginal
tion in non-preg-
nant women. of trimethoprim-sulfamethoxazole (TMP- estriol cream may help reduce the
Cochrane Database SMX) (40 mg TMP plus 200 mg SMX) result- frequency of symptomatic episodes.
Syst Rev. 2004:
CD001209. ed in an infection rate of 0.3 per patient per Estrogen therapy is associated with a
[PMID: 15266443] year, compared with a rate of 3.6 per pa- return of the premenopausal lacto-
15. Perrotta C, Aznar M,
tient per year in the control group (13). Side
Mejia R, Albert X, Ng bacillus-dominated vaginal flora, an
CW. Oestrogens for effects were infrequent and minor. In
preventing recurrent acid vaginal pH, and reduced vaginal
urinary tract infec- women intolerant of or resistant to TMP-
tion in post- SMX, an alternative agent (e.g., nitrofuran-
colonization with Escherichia coli. Two
menopausal
toin macrocrystals or a fluoroquinolone) studies in a 2008 Cochrane system-
women. Cochrane
Database Syst Rev. may be as effective for postcoital prophy- atic review compared vaginal estro-
2008:CD005131.
[PMID: 18425910] laxis as TMP-SMX, although clinical evi- gens with placebo and showed that
16. Bent S, Nallamothu dence specifically related to postcoital use vaginal estrogens reduced the num-
BK, Simel DL, Fihn
SD, Saint S. Does this is not available for these agents (13). ber of UTIs in postmenopausal
woman have an
acute uncomplicat-
women. Response varied according
ed urinary tract in- For women with more frequent re- to the type of estrogen and treatment
fection? JAMA.
2002;287:2701-10.
currences, more frequent coitus, or duration. Oral estrogens did not re-
[PMID: 12020306] recurrences temporally unrelated to duce UTI compared with placebo.
17. Gupta K, Hooton TM,
Roberts PL, Stamm coitus, continuous (daily, 3 times Drug-related events associated with
WE. Patient-initiated
treatment of un-
weekly, or even weekly) prophylaxis vaginal estrogens can include vaginal
complicated recur- may be preferable (14). Another itching, burning, discharge, and
rent urinary tract in-
fections in young approach, which is appropriate for metrorrhagia (15). A discussion of
women. Ann Intern women with recurrent, uncompli- possible cancer risk should be indi-
Med. 2001;135:9-16.
[PMID: 11434727] cated UTI unrelated to coitus, is vidualized for each patient.
18. Hooton TM, Bradley
SF, Cardenas DD, et
al; Infectious Dis-
eases Society of
America. Diagnosis,
prevention, and Screening and Prevention... Inappropriate screening for asymptomatic bacteriuria
treatment of can be detrimental because it can lead to unnecessary antibiotic use. Screening
catheter-associated and treatment of asymptomatic bacteriuria are not recommended in nonpregnant
urinary tract infec-
tion in adults: 2009 women, diabetic women, elderly persons, patients with spinal cord injury, or
International Clinical catheterized patients. Screening and treatment of asymptomatic bacteriuria is
Practice Guidelines
from the Infectious recommended only in pregnant women and patients about to have an invasive
Diseases Society of urologic procedure. Consider postcoital antibiotic prophylaxis for women with 2 or
America. Clin Infect
Dis. 2010;50:625-63.
more episodes of UTI per year, particularly if these are temporally associated with
[PMID: 20175247] coitus. Otherwise, daily or thrice-weekly antibiotic prophylaxis can be used to
19. Huppert JS, Biro F, prevent UTIs. Consider topical intravaginal estrogen therapy to prevent sympto-
Lan D, Mortensen JE,
Reed J, Slap GB. Uri- matic UTIs for postmenopausal women with recurrent UTIs.
nary symptoms in
adolescent females:
STI or UTI? J Adolesc
Health. 2007;40:418- CLINICAL BOTTOM LINE
24. [PMID: 17448399]

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Diagnosis and
What signs and symptoms should suprapubic pain, or subprapubic Evaluation
raise suspicion of UTI? tenderness are also compatible with
Diagnosis begins with a detailed CAUTI (18). 103 colony-forming
history because in ambulatory adult units/mL of urine or greater is suf-
women, the history provided by the ficient for the diagnosis of CAUTI
patient has high predictive value for with an indwelling or intermittent
the presence or absence of cystitis. catheter. By definition, CAUTI can
The most common symptoms in occur with indwelling urethral (Fo-
noncatheterized individuals include ley) catheters, suprapubic catheters,
dysuria, urinary frequency, and and condom catheters. Since many
urgency. of these defining symptoms are non-
specific, other infections and poten-
A meta-analysis of the accuracy of history
tial causes should be considered
and physical examination for diagnosing
acute, uncomplicated UTI in ambulatory
before attributing the symptoms to
women found that the probability of UTI was catheter-associated bacteriuria. The
approximately 50% in women who present- distinction between CAUTI and
ed with 1 or more symptoms of UTI. Specific catheter-associated asymptomatic 20. Saint S, Scholes D,
Fihn SD, Farrell RG,
combinations of symptoms raised the prob- bacteriuria is challenging but clinically Stamm WE. The ef-
ability to more than 90%. Symptoms that in- relevant, because only the former fectiveness of a clini-
cal practice guide-
creased the probability were dysuria, hema- should be treated with antibiotics. line for the
turia, and costovertebral angle tenderness. A management of pre-
sumed uncomplicat-
history of vaginal discharge or irritation de- What other disorders should be ed urinary tract in-
creased the probability of UTI (16). Longitudi- fection in women.
considered? Am J Med. 1999;
nal studies have shown that ambulatory The main alternative diagnoses to 106:636-41. [PMID:
adult women, particularly those who have 10378621]
consider in young women present- 21. Lachs MS,
had recurrent UTIs, are often able to accu- ing with symptoms of cystitis in- Nachamkin I, Edel-
rately identify symptoms of UTI (17). stein PH, Goldman J,
clude sexually transmitted urethritis Feinstein AR,
Schwartz JS. Spec-
A prospective trial enrolled women who or vaginitis, noninfectious urethritis, trum bias in the
had at least 2 episodes of cystitis in the pri- and early pyelonephritis (Table 1). evaluation of diag-
nostic tests: lessons
or 12 months from a university-based pri- Women who are sexually active are from the rapid dip-
stick test for urinary
mary care clinic. The participants were at risk for both UTIs and sexually tract infection. Ann
given urine collection materials and a transmitted diseases (STDs). Symp- Intern Med.
course of fluoroquinolone antibiotics, both 1992;117:135-40.
toms of STDs may be subtle, and [PMID: 1605428]
to be used if they developed symptoms thus they should always be consid- 22. Geerlings SE. Urinary
of UTI. Overall, 88 of 172 women self- tract infections in
ered in the differential diagnosis for patients with dia-
diagnosed a total of 172 UTIs. Laboratory betes mellitus: epi-
evaluation showed a uropathogen in 144
UTI. A history of vaginal discharge demiology, patho-

cases (84%), sterile pyuria in 19 cases (11%), or irritation decreases the probabili- genesis and
treatment. Int J
and no pyuria or bacteriuria in 9 cases (5%). ty of UTI and warrants a workup Antimicrob Agents.
2008;31 Suppl 1:S54-
Clinical and microbiological cures occurred for STDs and other vaginal condi- 7. [PMID: 18054467]
in 92% and 96%, respectively, of culture- tions, such as candidiasis (16). 23. Meron M, Regua-
Mangia AH, Teixeira
confirmed episodes. In this population, the LM, et al. Urinary
strategy of self-diagnosis and manage- A cross-sectional study screened 296 sexu- tract infections in re-
ally active females aged 14 to 22 years who nal transplant recipi-
ment of acute cystitis was highly effective. ents: virulence traits
were visiting a teen health center for both of uropathogenic Es-
UTI (by urine culture) and STD (by vaginal cherichia coli. Trans-
In catheterized patients, signs and plant Proc.
symptoms compatible with a swab and nucleic-acid amplification test- 2010;42:483-5.
ing). In this population, the prevalences of [PMID: 20304171]
CAUTI include new onset or wors- 24. Nicolle LE. Catheter-
ening fever, rigors, altered mental sta- UTI and STI were 17% and 33% respec- related urinary tract
tively; 4% had both. The presence or ab- infection. Drugs Ag-
tus, malaise or lethargy with no other ing. 2005;22:627-39.
sence of urinary symptoms did not predict [PMID: 16060714]
identified cause, flank pain, costover- STD, indicating that telephone manage- 25. Ulleryd P, Zackrisson
tebral angle tenderness, acute hema- ment may not be appropriate for adoles-
B, Aus G, Bergdahl S,
Hugosson J, Sand-
turia, or pelvic discomfort. In patients cent women with urinary symptoms (19). berg T. Selective uro-
logical evaluation in
whose catheters have been removed men with febrile uri-
within the past 48 hours, dysuria, The treating clinician should also nary tract infection.
BJU Int. 2001;88:15-
urgency, frequent urination, consider whether the patient could 20. [PMID: 11446838]

6 March 2012 Annals of Internal Medicine In the Clinic ITC3-5 2012 American College of Physicians

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Table 1. Differential Diagnosis of Acute Cystitis in Women
Condition Pathogens History Symptoms
Vaginitis Candida, Trichomonas vaginalis, Possibly new sex partner or unprotected Vaginal discharge, odor, or itching;
Bacteroides species, Gardnerella vaginalis sexual activity; history of vaginitis external dysuria (from urine coming
into contact with inflamed and irritated
vulvar epithelial surfaces)
Urethritis Chlamydia trachomatis, Neisseria New sex partner, unprotected sexual Gradual onset of symptoms (Chlamydia)
gonorrhoeae, or herpes simplex virus activity, history of sexually transmitted vaginal discharge; urinary frequency
diseases or genital herpes simplex or urgency
Irritation None No unusual sexual exposure; possible Vaginal itching or discharge; usually a
chemical or allergen exposures diagnosis of exclusion, unless withdrawal
(e.g., douches, bath products, feminine of a suspected offending substance
hygiene products, spermicides) resolves symptoms
Pyelonephritis Same as acute cystitis Previous UTI (pyelonephritis or cystitis) Constitutional symptoms (fever, malaise,
sweats, headache), gastrointestinal
symptoms (anorexia, nausea, vomiting,
abdominal pain), local renal symptoms
(back, flank or loin pain), voiding
symptoms (as in cystitis)

have pyelonephritis (or in men, organism and its antimicrobial sus-


prostatitis) before initiating therapy ceptibility. It is appropriate to ob-
for acute cystitis. The recom- tain a culture (with susceptibility
mended duration of therapy for testing) of a pretreatment urine
pyelonephritis is longer than that of sample for women with suspected
cystitis; treatment of incipient cystitis if the diagnosis is not clear
pyelonephritis with a short-course from the history and physical
regimen for cystitis could predis- examination, if an unusual or
pose the patient to relapse. antimicrobial-resistant organism is
Pyelonephritis may or may not be suspected, if the episode represents
associated with symptoms of cysti- a suspected relapse or treatment
tis, which in some patients may failure, or if the patients therapeu-
overshadow the renal or systemic tic options are limited by medica-
26. Abarbanel J, Engel- manifestations. In patients present- tion intolerance. Pretreatment urine
stein D, Lask D, Livne ing with symptoms of acute cystitis, culture is also considered standard
PM. Urinary tract in-
fection in men confirm the absence of fever, nau- of care in pregnant women and men.
younger than 45
years of age: is there sea, vomiting, rigors, and flank
a need for urologic pain. In men with urinary symp- Women presenting with classic
investigation? Urolo-
gy. 2003;62:27-9. toms and fever, consider both acute symptoms of cystitis (dysuria, fre-
[PMID: 12837416]
27. Gupta K, Hooton TM,
infectious prostatitis and/or quency) who do not have symptoms
Naber KG, et al; In- pyelonephritis in the differential. of possible alternative diagnoses or
fectious Diseases
Society of America.
International clinical What tests should be done to underlying complicating conditions
practice guidelines
diagnose UTI? may be treated for UTI without
for the treatment of
acute uncomplicat- Urine culture is generally not re- further testing. For such women,
ed cystitis and self-initiated therapy or telephone
pyelonephritis in quired in suspected cases of acute,
women: A 2010
uncomplicated cystitis because the clinic provider-guided presumptive
update by the Infec-
tious Diseases Socie- spectrum of causative organisms is therapy may be appropriate (20). In
ty of America and
the European Socie- predictable and urine culture results a woman presenting with symptoms
ty for Microbiology
are often not available until after of acute cystitis, a positive urine
and Infectious Dis-
eases. Clin Infect Dis. completion of short-course empiri- dipstick result can help to confirm
2011;52:e103-20.
[PMID: 21292654] cal treatments. The role of urine the diagnosis, but a negative dip-
28. Gupta K, Hooton TM,
Roberts PL, Stamm
culture is 2-fold: to provide retro- stick result cannot rule out the di-
WE. Short-course ni- spective confirmation of the pres- agnosis in a woman with a high
trofurantoin for the
treatment of acute ence of bacteriuria, which in the pretest probability of cystitis (16,
uncomplicated cys-
titis in women. Arch
correct clinical setting confirms the 21). Thus, a dipstick test is not
Intern Med. 2007; diagnosis of UTI, and to provide necessary if the history is clearly
167:2207-12. [PMID:
17998493] specific information about the diagnostic of UTI (particularly in

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women with symptoms akin to pre- pathogens above, Proteus, Mor-
vious episodes). ganella, and Providencia are com-
mon (24).
If the diagnosis is not clear-cut or
if further complicating factors or Interpretation of urine culture de-
alternative diagnoses emerges from pends on the clinical context and
the history, a more thorough and the urinalysis findings; the thresh-
broad-based diagnostic evaluation old of bacteriuria required for the
should be conducted. diagnosis of acute cystitis is not ab-
solute. Even a low concentration
Blood tests (including cultures) are (102 colony-forming units/mL) of
not indicated in women with sus- coliform bacteria in a urine sample
pected cystitis unless they are needed from a woman with acute dysuria
to screen for alternative diagnoses and pyuria often represents true
suggested by the history or physical (i.e., from within the urinary tract)
examination or to assess the status bacteriuria. Such organisms should
of a known underlying medical not be dismissed as contaminants
condition (e.g., diabetes mellitus). in a clinical setting suggestive of
Up to 30% of women with acute cystitis (e.g., a patient with irrita-
pyelonephritis may have secondary tive voiding symptoms plus pyuria).
bacteremia, and identification of the On the other hand, even high con-
organism by blood culture can be centrations (>105 colony-forming
helpful in cases where antibiotics are units/mL) of nonpathogens may
started in advance of the urine cul- not reflect true bacteriuria if the
ture. Diabetic women and renal urine specimen was not collected
transplant recipients have a higher properly or was allowed to stand at
incidence of secondary bacteremia room temperature before process-
with UTI (22, 23). ing. Organisms other than coliform
bacilli, S. saprophyticus, and Entero-
What organisms are generally coccus (e.g., lactobacilli, alpha strep-
found in UTI? tococci, and coagulase-negative
Escherichia coli is the pathogen iso- staphylococci other than S. sapro-
lated in more than 90% of patients phyticus) are usually considered con- 29. Falagas ME, Kastoris
with uncomplicated cystitis and taminants in urine cultures from AC, Kapaskelis AM,
pyelonephritis. Other coliforms, women with uncomplicated cysti-
Karageorgopoulos
DE. Fosfomycin for
including Klebsiella and Proteus, are tis, whereas in complicated UTI al- the treatment of
multidrug-resistant,
less common. Staphylococcus sapro- most any organism can be causative including extended-
phyticus is a coagulase-negative and must be considered seriously if spectrum beta-
lactamase produc-
staphylococcus that causes uncom- the patient is symptomatic. ing, Enterobacteri-
plicated cystitis and pyelonephritis aceae infections: a
systematic review.
in a small proportion (5%10%) of Is there a role for diagnostic Lancet Infect Dis.
2010;10:43-50.
otherwise-healthy women. Es- imaging in diagnosing UTI? [PMID: 20129148]
cherichia coli is still a predominant For uncomplicated bladder infec- 30. Falagas ME, Kotsan-
tis IK, Vouloumanou
pathogen in complicated UTI, but tions, expert consensus is that imag- EK, Rafailidis PI. An-
tibiotics versus
other coliforms and enterococci are ing studies (abdominal radiographs, placebo in the treat-
also common. CAUTI in patients ultrasonography, computed tomog- ment of women
with uncomplicated
with short-term catheters can be raphy, and excretory urography) add cystitis: a meta-
analysis of random-
caused by E. coli as well as by a little or no benefit but increase cost, ized controlled trials.
spectrum of typical hospital- cause delays, and carry some poten- J Infect. 2009;58:91-
102. [PMID:
acquired pathogens, including tial risk for the patient. Such studies 19195714]
31. Little P, Moore MV,
Klebsiella, Citrobacter, Enterobacter, should be done only if the pretest Turner S, et al. Effec-
Pseudomonas, coagulase-negative suspicion is high for an alternative tiveness of five dif-
ferent approaches in
staphylococci, enterococci, and diagnosis or an anatomical problem management of uri-
nary tract infection:
Candida. Patients with long-term (such as bladder obstruction or randomised con-
catheters typically have polymicro- stone) that would require interven- trolled trial. BMJ.
2010;340:c199.
bial infections; in addition to the tion. Although men with acute [PMID: 20139214]

6 March 2012 Annals of Internal Medicine In the Clinic ITC3-7 2012 American College of Physicians

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cystitis should be considered for 45 years who were hospitalized for
further evaluation for urologic ab- febrile UTI but were otherwise healthy.
normalities, imaging studies for Significant urethral stricture was ex-
acute cystitis in men younger than cluded in all patients by insertion of a
45 years or in older men without 16-French urethral catheter. Ultra-
any symptoms of voiding difficul- sonography and intravenous (IV) urog-
ties or hematuria may not be fruit- raphy were normal in all patients. Ten
ful. Unfortunately, the evidence base patients with hematuria had cys-
for male cystitis is limited (25). toscopy, and the urinary tract was
healthy in all 10. One patient (3%) had
A prospective study of UTI was done bladder outflow obstruction detected
in 29 consecutive men younger than by uroflowmetry (26).

Diagnosis and Evaluation... Diagnosis of UTI begins with a detailed history. In am-
bulatory adult women, the history provided by the patient has high predictive value
for the presence or absence of cystitis. Consider the diagnosis of pyelonephritis (or
in men, prostatitis) before starting therapy for acute cystitis. Consider complicating
factors, namely underlying medical or urologic conditions that may predispose to
treatment failure, infection with antibiotic-resistant organisms, or infectious com-
plications that would affect the appropriate diagnostic workup and course of thera-
py. Use urinalysis via dipstick, microscopy, or automated microscopy to confirm the
diagnosis in women with suspected UTI when the history alone is not diagnostic. Al-
ways culture the urine of patients with pyelonephritis, complicated UTI, men, preg-
nant women, or those with a history of failure of initial therapy. Initiate empirical
therapy and make adjustments based on the results of the urine culture, if done.

CLINICAL BOTTOM LINE


Treatment and
Management What are the preferred In addition to the usual concerns
treatments for UTI? for efficacy and safety, the 2010
32. Stapleton AE, Women with cystitis should be IDSA treatment recommendations
Dziura J, Hooton TM,
Cox ME, Yarova- treated with an appropriate antimi- for acute cystitis and pyelonephritis
Yarovaya Y, Chen S,
et al. Recurrent Uri-
crobial agent. Before selecting a were guided by 2 important princi-
nary Tract Infection treatment regimen for women with ples: the increasing prevalence of re-
and Urinary Es-
cherichia coli in presumed cystitis, ask about factors sistant organisms, and the potential
Women Injesting
that may influence the choice of for propagation of resistance (collat-
Cranberry Juice
Daily: A Randomized antimicrobial agent, including eral damage) among normal
Controlled Trial.
Mayo Clin Proc. pregnancy and breast-feeding, other host flora with the use of broad-
2012;87:143-50.
medications being taken, drug spectrum antibiotics. No single
[PMID:22305026]
33. Barbosa-Cesnik C, allergy history, recent antibiotic agent was designated as the pre-
Brown MB, Buxton
M, Zhang L, DeBuss- therapy, other recent infections or ferred regimen. Instead, agents are
cher J, Foxman B.
positive cultures, and recent travel. listed as recommended for first-line
Cranberry juice fails
to prevent recurrent Also, whether there are any compli- therapy (nitrofurantoin, TMP-SMX,
urinary tract infec-
cating factors should be determined pivemecillinam, and fosfomycin
tion: results from a
randomized place- trometamol) and alternative
bo-controlled trial. because management of uncompli-
agents (fluoroquinolones and beta-
Clin Infect Dis. cated cystitis and pyelonephritis
2011;52:23-30. lactams). Treatment regimens for
[PMID: 21148516] differs from that of complicated
34. Beerepoot MA, ter cystitis and pyelonephritis are listed
Riet G, Nys S, et al. UTI. The IDSA has recently pub-
in Tables 2 and 3, respectively.
Cranberries vs an-
tibiotics to prevent
lished updated guidelines for treat-
urinary tract infec- ment of uncomplicated cystitis and Each agent has its own caveats. Nitro-
tions: a randomized
double-blind nonin- pyelonephritis, specifically in pre- furantoin concentrates in the urine
feriority trial in pre- menopausal, nonpregnant women
menopausal
but has little tissue penetration and
women. Arch Intern with no known urologic abnormali- thus should be avoided if there is
Med. 2011;171:1270-
8. [PMID: 21788542 ties or comorbid conditions (27). any possibility of pyelo-nephritis.

2012 American College of Physicians ITC3-8 In the Clinic Annals of Internal Medicine 6 March 2012

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Table 2. Treatment Regimens for Acute Uncomplicated Cystitis
Drug Dose and Duration Common Side Effects Comments
Recommended agents
Nitrofurantoin 100 mg twice Nausea, headache Resistance rare to date; cost varies; usually well-tolerated;
monohydrate/ daily for 5 days generally safe in pregnancy
macrocrystals
Trimethoprim- 160/800 mg (one Rash, urticaria, nausea, Excellent efficacy if local resistance less than 20%; resistance
sulfamethoxazole DS tablet) twice vomiting, hematologic prevalence is increasing; inexpensive; extensive clinical experience;
daily for 3 days avoid during pregnancy, particularly first and third trimesters
Fosfomycin 3-g single-dose Diarrhea, nausea, May be useful for multidrug-resistant pathogens; may be less
trometamol sachet headache effective than other agents; safe in pregnancy
Alternative agents
Fluoroquinolones Dose varies by Nausea, vomiting, diarrhea, Prevalence of resistance increasing; cost varies; excellent
agent; 3day headache, drowsiness, efficacy; high collateral damage; better reserved for more
regimen insomnia serious conditions; avoid in pregnancy; tendon inflammation and
rupture have been reported with use of quinolone antibiotics
Beta-lactams Dose varies by Diarrhea, nausea, vomiting, Resistance varies by agent; increased adverse effects compared
agent; 57 day rash, urticaria with other options; safe during pregnancy
regimen

A 5-day course of nitrofurantoin but is used only for treatment of


was as effective as a 3-day course of UTI. Although efficacy rates are
TMP-SMX in terms of both clini- lower than those of the other rec-
cal and microbiological cure in a ommended agents, its low resistance
randomized trial (28). The main rates have made it a popular first-
limitation to the use of TMP-SMX line choice in some European coun-
is the rising rate of resistance tries. The fluoroquinolones,
among uropathogens, especially ofloxacin, ciprofloxacin, and lev-
outside the United States, and con- ofloxacin, are all highly efficacious
sistent evidence that in vitro resist- in 3-day regimens but are recom-
ance correlates with bacterial and mended as alternative agents be-
clinical failures in at least 50% of cause they have a high propensity
women. However, the 4 studies re- for collateral damage of the normal
viewed by the IDSA guidelines fecal flora. Increasing rates of fluoro-
committee showed that TMP-SMX quinolone resistance in certain areas
remains an appropriate empirical suggest that these agents should be
treatment for acute uncomplicated reserved for conditions other than
cystitis in women when the local acute cystitis. Beta-lactams in gener- 35. Talan DA, Stamm
WE, Hooton TM, et
rate of resistance is known or ex- al have inferior efficacy, high collat- al. Comparison of
ciprofloxacin (7 days)
pected to be < 20%. Fosfomycin is eral damage, and greater rates of and trimethoprim-
available in the United States but is adverse effects than other UTI sulfamethoxazole
(14 days) for acute
rarely used. The recommended 3-g antimicrobials and thus are also uncomplicated
pyelonephritis
single dose may not be as effica- considered alternative agents. pyelonephritis in
cious as other recommended agents, women: a random-
ized trial. JAMA.
and it should be not be used if Pyelonephritis is a tissue-invasive 2000;283:1583-90.
[PMID: 10735395]
pyelonephritis is suspected. Suscep- disease, and the initial empirical 36. Saint S, Meddings
tibility data are not routinely re- regimen should be broad enough to JA, Calfee D, Kowals-
ki CP, Krein SL.
ported for this drug, but surveys ensure in vitro activity against the Catheter-associated
urinary tract infec-
demonstrate that it retains activity uropathogen. In all suspected cases, tion and the
against multidrug resistant uropath- a urine culture would ideally be ob- Medicare rule
changes. Ann Intern
ogens, such as extended-spectrum tained for susceptibility testing be- Med. 2009;150:877-
84. [PMID:
beta-lactamaseproducing gram- fore starting therapy so the initial 1952856784]
negative organisms (29). Pivmecilli- empirical therapy can be tailored 37. Warye KL, Murphy
DM. Targeting zero
nam, which is currently unavailable appropriately. The decision points health care-associ-
ated infections [Edi-
in the United States, is an extend- in managing acute pyelonephritis torial]. Am J Infect
ed-spectrum penicillin that is active include ruling out complicated in- Control. 2008;
36:683-4. [PMID:
against gram-negative organisms fection (pregnancy, nephrolithiasis, 19084162]

6 March 2012 Annals of Internal Medicine In the Clinic ITC3-9 2012 American College of Physicians

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Table 3. Oral Treatment Regimens for Acute Uncomplicated Pyelonephritis*
Drug Dose and Duration Comments Other
Fluoroquinolones
Ciprofloxacin 500 mg twice daily for 7 d If local resistance prevalence is < 10% Consider adding an initial 1-time IV dose of a long-
Ciprofloxacin XR 1000 mg once daily for 7 d acting parenteral antimicrobial (such as 1 g of
Levofloxacin 750 mg once daily for 5 d ceftriaxone or a single 24-h dose of an amino-
glycoside) if the patient is borderline for oral
therapy but not meeting admission criteria or if
there may be a delay in starting oral therapy
Trimethoprim- 160/800 mg (one DS tablet) If pathogen known to be susceptible; Same as above
sulfamethoxazole twice daily for 14 days otherwise give an initial IV agent
Beta-lactams Dose varies by agent; Oral beta-lactams are less effective and Give an initial IV dose of a long-acting parenteral
10- to 14-d regimen should be used cautiously only when antimicrobial when using oral beta-lactams
other agents cannot be used

* For pyelonephritis, urine culture and susceptibility testing should always be done, with empirical treatment modified based on the results.

obstruction) and then determining Urinary analgesics for acute cystitis of fluoroquinolone resistance ex-
whether the patient can take oral an- are appropriate in certain situations ceeds 10%, another broad-spectrum
tibiotics as an outpatient. If oral thera- to speed resolution of bladder dis- antimicrobial should be considered,
py is feasible, oral ciprofloxacin in a comfort. The analgesic phenazopy- including an extended-spectrum
7-day regimen is the preferred regi- ridine is widely used but may cause cephalosporin with or without an
men if local resistance rates to the nausea. Combination analgesics aminoglycoside or a carbapenem.
fluoroquinolones do not exceed 10%. containing urinary antiseptics Combinations of a beta-lactam and a
The extended-release formulation of (methenamine, methylene blue), a beta-lactamase inhibitor (e.g.,
ciprofloxacin for 7 days or a once- urine-acidifying agent (sodium phos- ampicillin-sulbactam, ticarcillin-
daily dose of levofloxacin for 5 days phate), and an antispasmodic agent clavulanate, and piperacillin-
can also be used, albeit the evidence is (hyoscamine) are also available. tazobactam) could also be considered.
not as robust (27). TMP-SMX is also Because these analgesics can mask the
The IDSA has issued evidence-based
effective if the pathogen is susceptible, symptoms of antimicrobial failure,
guidelines on the diagnosis, preven-
but in the absence of evidence to sup- they are best used in patients with a
tion, and treatment of CAUTI (18).
port short-course therapy a 14-day clear diagnosis of cystitis.
The goal of limiting exposure to an-
course is the official recommendation.
Patients with underlying compli- timicrobial therapy and thus limiting
If susceptibility of the uro-pathogen is selection pressure for resistant organ-
not known, an initial single IV dose cating conditions are more likely
to have a drug-resistant organism, isms is balanced by the awareness
of ceftriaxone or a long-acting amino- that microbial eradication requires a
glycoside is recommended before to exhibit a poor response to anti-
microbial therapy even when the longer duration of therapy in patients
outpatient oral therapy. In a study with a urinary catheter. Seven days is
comparing ciprofloxacin to TMP- urine organism is susceptible, and to
develop complications if initial ther- the recommended duration of anti-
SMX, an initial dose of IV ceftriaxone microbial treatment for patients
resulted in improved outcomes in apy for UTI is suboptimal. Broader-
whose symptoms resolve promptly,
women receiving TMP-SMX who spectrum empirical therapy with
and 10 to 14 days is recommended
had a resistant uropathogen. Oral agents to which resistance is least
for patients with a delayed response.
beta-lactam agents are not recom- common and longer treatment dura-
For those with CAUTI who are not
mended for treatment of pyelonephri- tions are measures intended to blunt
severely ill, a 5-day regimen of lev-
tis given inferior efficacy rates. the negative effects of host compro-
ofloxacin may be considered (18).
mise on treatment outcomes. In
In women being admitted for IV ther- clinical trials of therapy for compli- In pregnant women with sympto-
apy, a broad-spectrum agent should be cated UTI, oral fluoroquinolones matic UTI, a urine culture and
given until the susceptibilities of the were as effective as traditional iv susceptibility testing should be per-
organism are known. This can be regimens and as or even more formed. Empirical therapy with an
achieved with a carbapenem agent, effective than oral TMP-SMX or oral antimicrobial agent that is safe
an aminoglycoside with or without TMP (particularly for organisms for use in pregnancy should be
ampicillin, or extended spectrum beta- resistant to TMP-SMX). However, given for 3 to 7 days for cystitis or
lactam with or without an aminogly- resistance to fluoroquinolones 7 to 14 days for pyelonephritis. An-
coside, or another regimen chosen on among uropathogens is increasing tibiotic therapy should be adjusted
the basis of local resistance patterns. worldwide. If the local prevalence on the basis of culture results.

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Is there a role for nonpharmcologic well as a reduction in urinary P-fimbriated What are the usual reasons for
therapies in treating UTI, including E. coli; however, the study was under- failure of UTI therapy?
alternative therapies? powered to reach statistical significance Underlying medical conditions that
There is no defined role for nondrug for either outcome (32). Another recent, increase the risk for delayed or
therapy in managing acute cystitis. Pa- randomized, controlled trial of twice-daily incomplete response to therapy, re-
cranberry juice consumption versus place-
tients may have heard of supposed lapse, or infectious complications in-
bo did not find a difference in the rate of
adjunctive or alternative measures to clude pregnancy, poorly controlled
UTI recurrence between the groups (33). An-
UTI therapy, and may want guidance other randomized study compared cran- diabetes mellitus, and immunosup-
on their use. Advise patients that in- berry capsules with TMP-SMX and showed pression. Advanced age, recent
creased fluid intake, consumption of that the antibiotic was more effective at UTIs, recent antibiotic use, previous
cranberry juice, acupuncture, and other preventing recurrent UTI, albeit at the ex- infection with resistant organism,
nondrug approaches to the manage- pense of promoting antibiotic resistance prolonged duration of symptoms
ment of cystitis are of no known bene- (34). At this point there is no definitive before presentation (>3 d), and re-
fit. Patients should be counseled that evidence that commercially available cran- cent travel to an area with a high
relying on nondrug therapies to treat berry products can be used for treating or prevalence of antibiotic-resistant
acute cystitis is essentially similar to preventing UTI. uropathogens all increase the risk for
treating the condition with a placebo. resistant infection. Urologic compli-
When should patients be
A meta-analysis of 5 trials of placebo cations that can put the patient at
hospitalized for UTI?
vs. antibiotic therapy for uncompli- risk for treatment failure include uri-
Uncomplicated cystitis by definition
cated cystitis showed that antibiotic nary tract stones, voiding disorders,
does not require hospitalization, but
therapy was clearly superior for indwelling catheters, stents, urinary
complicated cystitis or pyelonephritis
achieving symptom resolution (OR, obstruction, duplicated collecting sys-
may require inpatient management.
4.8; CI, 2.59.2) and microbio-logical tem or other anatomical abnormali-
Factors for which hospitalization
cure (OR, 10.7; CI, 2.9638.4) (30). ties, or vesicoureteral reflux. The
may be necessary include serious co-
combination of obstruction and in-
A randomized, controlled trial of 5 ap- morbid conditions, including preg-
fection puts the patient at increased
proaches to management of UTI in non- nancy. Patients with a high fever, risk for upper UTI (pyelonephritis),
pregnant adult women found that all dehydration, high leukocyte count, or sepsis, and perinephric or intrarenal
approaches achieved similar symptom con- other evidence of sepsis may require abscess. In particular, patients with
trol, but women who delayed the start of an- inpatient supervision, as do those CAUTI who do not promptly re-
tibiotics had a longer duration of symptoms. who are vomiting and thus unable to
The 5 strategies tested were immediate an- spond to appropriate antibiotic therapy
take oral therapy. Another considera- may have obstruction or stones in the
tibiotics, delayed empirical antibiotics for tion is whether the patient has an
persistent symptoms, antibiotics based on a upper urinary tract. Effective urine
upper urinary tract condition that drainage reduces intraluminal pres-
symptom score, antibiotics based on dip-
would require drainage or surgical in- sure and restores the flow of urine.
stick results, and antibiotics based on a pos-
itive urine culture result (31). This finding is in tervention, including abscesses, em-
accord with the meta-analysis of Bent and physematous pyelonephritis, papillary When should clinicians consider
colleagues (16), which found that women necrosis, or xanthogranulomatous consultation with a specialist?
who present with symptoms of UTI have a pyelonephritis. On rare occasions, a Consultation is rarely needed for
high pretest probability of UTI and will prob- patient will have a multidrug-resistant acute, uncomplicated cystitis in am-
ably require treatment for UTI unless anoth- urine organism that is susceptible bulatory women but can be helpful
er explanation for their symptoms is found. only to parenterally administered an- in complicated UTI, particularly in
timicrobial agents or is intolerant of patients with indwelling bladder
The patient may raise the issue of agents that can be given orally. How- catheters, those hospitalized because
cranberry products to prevent or to ever, many women with pyelo- of upper tract disease, and men with
treat UTI. Cranberries contain sub- nephritis can be managed successfully UTI. Consider consulting an in-
stances that inhibit certain adhesins at home, as treatment trials have fectious disease specialist when the
of uropathogenic E. coli, thereby shown the efficacy of oral therapy organisms isolated in the urine are
preventing the bacteria from adher- with a fluoroquinolone for mild, acute resistant to standard antibiotics.
ing to human cells. However, these pyelonephritis in this group (35). Consultation with an infectious dis-
in vitro findings have not yet been Clinical judgment is required to eases specialist or a urologist may also
proven to have clinical relevance. determine which patients are appro- be necessary in patients with possible
A recent randomized trial attempted to priate for outpatient management, upper urinary tract involvement who
address this issue and found a potentially and a period of observation in do not respond to appropriate antibi-
protective effect on recurrent UTI with cran- the emergency department may be otic therapy within 72 hours. A
berry products compared with placebo as warranted. surgically correctable lesion may be

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present in men who report voiding multiple predisposing conditions,
difficulties or acute urine retention or multiple medication allergies
or who have early recurrent UTI or need closer follow-up than do pa-
persistent microscopic hematuria. tients with only mild symptoms, an
Stones, strictures, and occult cancer easily-treated organism, a single
are among the differential diagnoses minor predisposing condition, and
for men with these symptoms. otherwise good health status. Pa-
tients with complicated UTI should
How should patients treated for be followed clinically for sympto-
UTI be followed? matic resolution and be reevaluated
In uncomplicated cystitis, no specific if symptoms do not improve within
follow-up is required as long as 24 to 48 hours, worsen, or recur
symptoms resolve. In pregnant quickly after therapy. In CAUTI, it
women, obtain urine cultures after is important to monitor response to
treatment to confirm eradication of therapy by the patients symptoms
bacteriuria, and obtain repeated uri- rather than by repeated urine cul-
nalyses or urine cultures at intervals tures, as recurrent bacteriuria is the
to confirm sterility of the urine norm in patients whose indwelling
through the time of delivery. The ra- catheter remains in place.
tionale for repeated screening is that
pregnant women who have already What is the correct approach to
had bacteriuria during their pregnan- secondary prevention in patients
cy are at increased risk for recurrence who have a history of UTI?
and need closer monitoring than do Recurrent UTI is very common, es-
women who had sterile urine on ini- timated to occur in up to 50% of
tial screening. However, more evi- women within 1 year of an initial
dence is needed to define the appro- UTI (3). Other than the antimicro-
priate frequency of follow-up cultures bial prophylaxis recommended in
and retreatment strategies (10). the Prevention section above, there
are few measures that women can
It seems prudent to monitor patients take to prevent recurrent UTI.
with complicated UTI during and As for the often-cited behavioral
after therapy, because failure of ther- risk factors for recurrent UTI, a
apy for cystitis in the presence of un- large casecontrol study in pre-
derlying complicating conditions is menopausal women did not find
both more probable and more likely any associations between risk for
to produce significant morbidity recurrent UTI and pre- and post-
than in patients without complicat- coital voiding, frequency of urina-
ing conditions. Because complicated tion, wiping patterns, douching,
UTI is an extremely heterogenous use of hot tubs, frequent use of panty-
disorder, the approach to monitoring hose or tights, or daily fluid con-
during and after therapy must be in- sumption (2). Women with recurrent
dividualized. Patients who are more UTI should be counseled about the
fragile, are infected with more diffi- true risk factors for UTI so they do
cult-to-treat organisms, have more not blame themselves or make un-
severe symptoms at the outset, necessary behavioral changes.

Treatment and Management... The IDSA has recently released new standard-of-
care guidelines for treatment of acute, uncomplicated cystitis; acute uncompli-
cated pyelonephritis; and catheter-associated UTI. Nonpharmacologic therapies
for acute cystitis do not have proven benefits and may lead to adverse outcomes.
Posttreatment follow-up should include monitoring the response to therapy
rather than repeated urine cultures, except in pregnant women.

CLINICAL BOTTOM LINE

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Practice
What measures do U.S. stakeholders important social change affecting
Improvement
use to evaluate the quality of care CAUTI research and prevention
for patients with UTI? efforts has been the upsurge in
The recent guidelines on acute un- public reporting of hospital quality-
complicated cystitis and of-care data. Although CAUTI is
pyelonephritis published by the not among the standard outcome of
IDSA in 2011 identified several care measures, prevention of
performance measures as appropri- CAUTI has been announced as a
ate indicators for management of 2012 National Patient Safety Goals
acute uncomplicated UTI in by the Joint Commission. Therefore,
women. Use an available recom- monitoring for appropriate urinary
mended antimicrobial for treatment catheter care and use is rapidly be-
of uncomplicated cystitis and un- coming standard hospital policy.
complicated pyelonephritis if the
patient is not allergic. Use fluoro- What do professional organizations
quinolones for acute uncomplicated recommend regarding care of
cystitis only when a recommended patients with UTI?
antimicrobial cannot be used. Ob- Professional organizations in both
tain a pretherapy urine culture in the United States and internation-
cases of acute uncomplicated ally have released practice guide-
pyelonephritis; start empirical lines concerning UTI that address
therapy and modify according to 3 categories of UTI: acute cystitis,
culture results. In other words, flu- CAUTI, and asymptomatic bac-
teriuria. The IDSA published the
oroquinolone antibiotics should not
Guidelines for Antimicrobial
be the first choice agents for acute,
Treatment of Acute Uncomplicated
uncomplicated cystitis, and urine
Cystitis and Pyelonephritis in
culture results should be used to
Women in 2011. These guidelines
guide therapy in pyelonephritis
focus on treatment of women with
(27). CAUTI has been in the spot-
acute uncomplicated cystitis and
light recently because of several
pyelonephritis, and their recom-
important social changes. On
mendations are limited to pre-
1 October 2008, the Centers for
menopausal, nonpregnant women
Medicare & Medicaid Services
with no known urologic abnormali-
stopped reimbursing U.S. hospitals
ties or comorbid conditions. An
for several complications of hospi-
important and unifying theme in
talization, including CAUTI that these guidelines is that the issues of
develops during hospitalization. in vitro resistance prevalence and
Although the rule has provoked the potential for collateral damage
controversy over whether CAUTI by various antimicrobial agents are
is truly preventable, the increased taken into account in the recom-
focus on prevention of this disor- mended treatment choices.
der, particularly through decreasing
unnecessary use of urinary CAUTI has received considerable
catheters, is likely to be beneficial press lately. Guidelines concerning
(36). Around the same time, the management and prevention of
focus of infection control agencies this condition have been released
shifted from control of hospital- by the Centers for Diseases Con-
acquired infections to prevention, trol Healthcare Infection Control
as summarized in the mission Practices Advisory Committee, by
statement of the Targeting Zero the Association for Professionals in
campaign of the Association for Infection Control and Epidemiolo-
Professionals in Infection Control gy in its Compendium of Strategies
and Epidemiology (37). The other to Prevent Healthcare-Associated

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Infections in Acute Care Hospitals, procedures). These IDSA guide-
and also by the IDSA. This topic lines recommendations were
is also addressed in the very com- reviewed and endorsed by the
prehensive European Association U.S. Preventive Services Task Force
of Urologists Guidelines on Uro- in 2008. Specifically, the Task
logical Infections released in 2009. Force recommended against screen-
ing for asymptomatic bacteriuria
Asymptomatic bacteriuria guide- in men and nonpregnant women
lines were published by the IDSA and recommended for screening
in 2005. Abundant evidence sup- for asymptomatic bacteriuria
ports nontreatment of asympto- with urine culture for pregnant
matic bacteriuria (with the women at 12 to 16 weeks gestation
exceptions of pregnant women or at the first prenatal visit, if
and patients undergoing urologic later.

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Tool Kit
PIER module on UTI from the American College of Physicians
(ACP). PIER modules provide evidence-based, updated
information on current diagnosis and treatment in an electronic
format designed for rapid access at the point of care.
Patient Information
www.annals.org/intheclinic/toolkit-uti.html
Urinary Tract Patient information that appears on the next page for duplication
and distribution to patients.
Infection www.nlm.nih.gov/medlineplus/ency/article/000483.htm
www.nlm.nih.gov/medlineplus/spanish/ency/article/000483.htm
Information on catheter-associated UTIs from the National
Institutes of Healths MedlinePLUS, in English and Spanish.
http://familydoctor.org/online/famdocen/home/women/
gen-health/190.html
Frequently asked questions on UTIs in women from the American
Academy of Family Physicians.
http://kidney.niddk.nih.gov/kudiseases/pubs/uti_ez/ (English)
http://kidney.niddk.nih.gov/spanish/pubs/uti_ez/ (Spanish)
A handout titled What I need to know about Urinary Tract
Infection from the National Institute of Diabetes and Digestive
and Kidney Diseases (NIDDK), in English and Spanish.
Clinical Guidelines
www.annals.org/content/149/1/W-20.full
Recommendation statement on screening for asymptomatic
bacteriuria in adults from the U.S. Preventive Services Task Force.
http://cid.oxfordjournals.org/content/50/5/625.full
International clinical practice guidelines from the Infectious Diseases
Society of America on the diagnosis, prevention, and treatment of
catheter-associated UTI in adults, released in 2009.
Diagnostic Tests and Criteria
http://pier.acponline.org/physicians/diseases/d162/tables/d162-tlab.html
Table listing laboratory and other studies for acute cystitis in women.
Quality of Care Guidelines
http://qualitymeasures.ahrq.gov/browse/by-topic-detail.aspx?
id=13254&ct=1&term=urinary
AHRQ quality indicators for UTI, including measures on the hospital
admission rate of UTI and the percentage of nursing home
residents with UTI.
www.annals.org/content/144/2/116.full
Systematic review on antimicrobial urinary catheters to prevent
catheter-associated UTI in hospitalized patients published in
Annals of Internal Medicine in 2006.

2012 American College of Physicians ITC3-14 In the Clinic Annals of Internal Medicine 6 March 2012

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THINGS YOU SHOULD In the Clinic
Annals of Internal Medicine
KNOW ABOUT URINARY
TRACT INFECTION

What is a urinary tract infection (UTI)?


A UTI is a common infection of the urinary system
(i.e., urethra, bladder, ureters, and kidneys).
It occurs when bacteria at the opening of the urethra
ascend to the bladder.
Infection limited to the urethra is called urethritis.
Infection that moves from the urethra to the bladder
is called cystitis.
Infection that moves further up the urinary tract to
the kidneys is called pyelonephritis.

What factors increase the risk for UTI?


Being a sexually active adult woman.
Using a diaphragm or spermicide.
Having an abnormality of the urinary tract that
obstructs the flow of urine (such as a kidney stone
or enlarged prostate gland).
Having a catheter (a tube inserted in the urethra
and bladder of people who cannot pass urine or who
lack bladder control).
Having poorly controlled diabetes in postmenopause.

What are common symptoms?


Painful urination and feeling an urgent need to
urinate frequently. If you have recurrent or resistant infection, your doc-
Urine that contains blood or looks cloudy. tor may order tests to determine if your urinary sys-
Discomfort in the lower abdomen and pain in the tem is normal.
back or pelvic area.
Fever may develop. How is it treated?

Patient Information
Your doctor will prescribe an oral antibacterial drug.
How is it diagnosed? It is important to take the full course of treatment
Your doctor may diagnose UTI based on your even if your symptoms disappear.
symptoms or may do additional tests. Patients with severe kidney infections may need to
Your urine is checked for evidence of infection with be hospitalized and receive IV treatments.
a test called a urinalysis or dipstick. If you have recurring infection, you may be advised
A urine culture for bacteria if you are pregnant or to take low doses of an antibiotic daily for many
are likely to have a kidney infection or resistant months or to take a single dose of an antibiotic after
bacteria. sexual intercourse to prevent infection.

For More Information


www.urologyhealth.org/urology/index.cfm?article=47
Information on urinary tract infections in adults from the
American Urological Association.

http://familydoctor.org/online/famdocen/home/women/
gen-health/284.html
Answers to questions about painful urination, from the American
Academy of Family Physicians.

http://womenshealth.gov/publications/our-publications/fact-sheet/
urinary-tract-infection.cfm
Urinary tract infection fact sheet from the U.S. Department of
Health and Human Services Office on Womens Health.

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CME Questions

1. A 64-year-old woman is evaluated for 3. An otherwise-healthy 28-year-old 4. A 32-year-old sexually active woman
symptoms of a urinary tract infection woman has had 2 episodes of acute with type 1 diabetes mellitus is evaluated
(UTI). She has had 3 UTIs in the past cystitis within the past 6 months. The because of recurrent UTIs. She has had
2 years. She is not sexually active. She patient is sexually active and has 3 episodes this year. The most recent
has no other medical problems and takes intercourse with her husband on average episode occurred 2 weeks ago. Physical
no medications. A pelvic examination 2 times per week and says her cystitis examination, including vital signs, is
reveals pale, dry vaginal epithelium that does not seem to be intercourse-related. normal. Urinalysis is normal except for
is smooth and shiny with loss of most Each time, symptoms remit after a the microscopic examination, which
rugation. Urinalysis reveals 2+ leukocyte single course of trimethoprim- shows 4+ bacteria.
esterase, leukocytes too numerous to sulfamethoxazole. The patient is Which of the following management
count, and 10 to 20 erythrocytes/hpf. currently asymptomatic but will be strategies is most appropriate at this
Urine culture grows escherichia coli. traveling abroad for the next 2 months time?
In addition to treating the current UTI, and is concerned about recurrent
infections. Her only medication is an oral A. Patient-initiated empiric antibiotic
which of the following is the most
contraceptive for birth control. She therapy
reasonable management option for this
reports no allergies. B. Continuous standard-dose antibiotic
patient?
therapy
A. Continuous antibiotic prophylaxis Which of the following is the most
C. Urinalysis and culture at the onset of
appropriate management?
B. CT imaging of the abdomen and dysuria
pelvis A. Ciprofloxacin after intercourse D. Postcoital empiric antibiotic therapy
C. Topical estrogen therapy B. Ciprofloxacin for 10 days when
D. Vaginal lubricants symptoms develop
C. Trimethoprim chronic suppressive
2. A 65-year-old woman is evaluated therapy
because a screening urine culture for D. Trimethoprim-sulfamethoxazole for
an insurance policy grows greater than 3 days when symptoms develop
105 colony-forming units/mL of E. coli.
She does not have fever, dysuria, urinary
frequency, or other symptoms. Medical
history is unremarkable. She has no
allergies and takes no medications.
Physical examination findings are normal.
Which of the following is the most
appropriate treatment?
A. Amoxicillin
B. Ciprofloxacin
C. Trimethoprim-sulfamethoxazole
D. No treatment

Questions are largely from the ACPs Medical Knowledge Self-Assessment Program (MKSAP, accessed at
http://www.acponline.org/products_services/mksap/15/?pr31). Go to www.annals.org/intheclinic/
to complete the quiz and earn up to 1.5 CME credits, or to purchase the complete MKSAP program.

2012 American College of Physicians ITC3-16 In the Clinic Annals of Internal Medicine 6 March 2012

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