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GENERAL DATA: J.P.

, 30, female, single, Filipino, call center agent, Roman Catholic, born Aug 7,
1979, presently residing at Road 7 Sanyo Novaliches Quezon city. Consulted for the first time in
our institution.

CHIEF COMPLAINTS painful urination

HISTORY OF PRESENT ILLNESS:

7 days prior to consult, patient experienced painful urination characterized as dull, non
radiating and tolerable. With no associated fever, chills, nausea, vomiting, flank pain, low back
pain, frequency, urgency, hesitancy, dribbling, retention, hematuria, change in urine caliber,
passage of stone or sandy material, and genital pruritus and discharge. No medication was taken,
no consult done.

3 days prior to consult, still with painful urination of unaltered character, now with associated
documented fever of 38.5°C, chills, and flank pain. With no associated frequency, urgency,
hesitancy, dribbling, hematuria, change in urine caliber and genital pruritus and discharge. Patient
self-medicated with ibuprofen 325mg paracetamol 200mg (Alaxan) once and paracetamol
(biogesic) 500mg every 6 hours which offered temporary relief of fever. However, painful urination
persisted. Still no consult done.

One day prior to consult, still with painful urination and associated symptoms. Patient took
amoxicillin 500mg 2 x a day for flank pain and paracetamol 500mg every 6 hours which afforded
temporary relief of fever and flank pain. Still no consult done.

Three hours prior to consult, with the persistence of the above signs and symptoms prompt
the patient to seek consult in our institution.

PAST MEDICAL HISTORY


Patient had an unrecalled immunizations. Had measles, mumps and chickenpox during
childhood. With history of hospitalization at 2001 diagnosed with urinary tract infection in
pregnancy for 5 days and was prescribed with cefalexin of unrecalled dose for which she was
compliant, resolved. At 2004, patient was again diagnosed by physician with UTI and was given
Ofloxacin of unrecalled dose taken 2x a day for 7 days, resolved. Patient has no history of
accidents, surgeries, blood transfusions, trauma and allergies to food and drugs. She denies any
history of hypertension, diabetes, asthma, pneumonia, tuberculosis, goiter, liver and kidney
disease and cancer.

FAMILY HISTORY;
Her father 62 years old and her mother 57 years old both are alive and apparently well. Her
four other siblings are alive and well. Has a family history of hypertension and diabetes on paternal
side and , asthma on maternal side. She denies of other heredo- familial diseases like liver and
kidney disease and cancer. She denies of any familial diseases such as pneumonia, pulmonary
tuberculosis and hepatitis.

PERSONAL AND SOCIAL HISTORY:


She is the 2nd among 5 siblings, finished a 2-year course of computer secretarial, currently
working as a call center agent. She lives in a 2- storey concrete house with four occupants,
situated in a residential area, not near any major roads, creeks and factories with 2 bedrooms, 4
windows-well lighted and ventilated, with 1 comfort room with manually flushed toilet. Water supply
and unboiled drinking water from Maynilad, garbage is collected twice a week, she prefers to eat
meat, fish and vegertables, drinks 3-4 glasses of water/ day, she is fond of eating sweet and salty
foods, smokes 3 sticks / day for 2 years(0.3 packyears), an occasional alcohol beverage drinker
consuming 2 bottles of beer per session, with poor perineal hygiene and has a habbit of holding
urine while at work.

OB/GYNE HISTORY:

Menarche at 13 years old, with regular interval, lasting for 5 days consuming 3-4 pads per
day, moderately soaked with associated headache and dysmenorrhea. Last menstrual period was
May 15-20, 2010 and previous menstrual period was last April 15-20 , 2010. Her ob score is G3P2
(2-0-1-2)

G1 - 1998 – full term -- NSD – Physician - UERM- (-) FMC


G2 – 2001 – Abortion -- D&C – San Juan Med Center – (-) FMC
G3 – 2002 – Full term – NSD – Physician - UERM – (-) FMC

REVIEW OF SYSTEMS

Skin: no rash, no itching, no scaling


Head and Neck: no headache, no stiffness , no trauma,
Eyes: no blurring of vision, no diplopia, no redness, no dryness
Ears: no hearing loss, no tinnitus, no discharge
Nose: no colds/no nasal stuffiness, no discharge, no bleeding,
Mouth and Throat: no ulcers, no gum bleeding, no hoarseness, no sore throat
Respiratory: no cough, no hemoptysis, no pleuritic chest pain
Cardiac: no chest pain, no dyspnea, no PND, no orhtopnea, no palpitations
Endocrine: no polyuria, no polydypsia, no polyphagia, no heat and cold intolerance
Nervous: No seizures, no syncope, no tremors

PHYSICAL EXAM:

General survey: Patient is conscious, coherent, ambulatory not in cardiorespiratory distress with
the following vital signs:.

BP – 100/70 Temp- 36.7 PR: 75 RR: 20 Weight 42 kg Height 152 cms BMI : 18 kg/m2
(underweight)

HEENT: anicteric sclera, pink palpebral conjunctiva, no nasoaural discharge , no


cervicoloymphadenopathy, no anterior neck mass, no neck vein engorgement

CHEST AND LUNGS: symmetrical chest expansion, no retractions, no lagging, equal and vocal
tactile fremitus, clear breath sounds
HEART: adynamic precordium, point of maximal impulse at 5th ICS left midclavicular line, normal
rate with regular rhythm, no murmurs.

ABDOMEN: flat abdomen, normoactive bowel sounds, soft, non tender on deep and light palpation.
Positive right kidney punch test. Negative rovsings, psoas and obturator sign. No rebound
tenderness.

EXTREMITIES: grossly normal extremities, no cyanosis, no edema, with full and equal pulses on
radial, brachial and dorsalis pedis artery

Internal Examination: External genitalia is grossly normal, vagina accepts 2 finger with ease, cervix
is firm, non-tender, no foul smelling vaginal discharge, no bloody discharge, no mass noted,no
tenderness, uterus is not enlarged

Tourniquet test: Negative

Initial assessment> Acute uncomplicated pyelonephritis


R/O Dengue fever

Initial Plan> For urinalysis


For CBC with APC
To come back with results
advised

Progress Notes

S> Patient came back with CBC with APC and Urinalysis result. Patient still complains of
dysuria and flank pain. No fever and no chills.

O> Patient is conscious, coherent, ambulatory, not in cardiorespiratory distress with the
following vitals signs of:
BP: 100/ 70 mmhg PR: 75 bpm RR: 19 cpm Temp 36.5

Flabby normoactive bowel sounds soft, non tender on light and deep palpation. (+)
right kidney punch test

A> Acute Uncomplicated Pyelonephritis


P> Ciprofloxacin 500 mg / tab , 1 tablet every 12 hours for 7 days
Increase oral fluid intake
Good perineal hygiene emphasized
To come back after 3 days
Advised

URINALYSIS;
MACROSCOPIC ANALYSIS:
Color – yellow
Transparency – turbid
CHEMICAL ANALYSIS
Reaction – alkaline
Specific gravity – 1.015
Sugar – negative
Protein – negative

MICROSCOPIC ANALYSIS
RBC – 15-20
WBC – 25-30
EPITHELIAL CELLS – many
BACTERIA – many

HEMATOLOGY
WBC ct: 4.04 x109/L
Segmenters: 0.62
Lymphocytes: 0.28
Monocytes: 0.09
Eosinophils: 0.01

Platelet count: 341 x109/L


Hemoglobin: 131 g/dl
Hematocrit : 0.42

Salient features:

This is a case of a 30 year old, female who came in with a chief complaint of painful urination

With associated:

Fever
Chills
Flank pain

With no associated:
Nausea
Vomiting
Frequency
Urgency
Hesitancy
Dribbling
Retention
Hematuria
Change in urine caliber
Passage of stone or sandy material
Genital pruritus and discharge
On PMH:
(+) History of Urinary tract infections last 2001 and 2004
(-) history of kidney disease
On FH:
(+) family history of Hypertension and Diabetes on paternal side

On Psychosocial history:
She is fond of eating sweet and salty foods
Drinks 3-4 glasses of water/ day
Has a habit of holding urine
With poor perineal hygiene
Physical Examination was centered on:
ABDOMEN: flat abdomen, normoactive bowel sounds, soft, non tender on deep and light
palpation. Positive kidney punch test. Negative rovsings, psoas and obturator sign. No
rebound tenderness.

Internal Examination: External genitalia is grossly normal, vagina accepts 2 finger with
ease, cervix is firm, non-tender, no foul smelling vaginal discharge, no bloody, no mass noted,
uterus is not enlarged.

Initial assessment> Acute uncomplicated pyelonephritis


R/O Dengue fever

Initial Plan> For urinalysis


For CBC with APC
To come back with results
advised

Progress Notes

S> Patient came back with CBC with APC and Urinalysis result. Patient still complains of
dysuria and flank pain. No fever and no chills.

O> Patient is conscious, coherent, ambulatory, not in cardiorespiratory distress with the
following vitals signs of:
BP: 100/ 70 mmhg PR: 75 bpm RR: 19 cpm Temp 36.5

Flabby normoactive bowel sounds soft, non tender on light and deep palpation. (+)
kidney punch test

A> Acute Uncomplicated Pyelonephritis

P> Ciprofloxacin 500 mg / tab , 1 tablet every 12 hours for 7 days


Increase oral fluid intake
Good perineal hygiene emphasized
To come back after 3 days
Advised
Anatomy
The kidneys
• paired retroperitoneal organs
• the right kidney is 0.5in (12mm) lower than the left
• Each measures approximately 4.5in long, 2.5in wide and 1.5in thick.
• Excretes waste products of metabolism
• Controls water and electrolyte balance in the body
• maintains acid and base balance in the blood
• Anatomic relations:
o Posteriorly: diaphragm, psoas, transversus abdominis, 12th rib and 3 nerves;
subcostal, iliohypogastric and ilio-inguinal
o Anteriorly: right kidney- liver, duodenum(2nd part), & ascening colon. left kidney-
stomach, spleen, pancrease and its vessels & desc. colon. adrenals sit on each as
a cap on the kidney's upper pole
• Renal hilum- a deep vertical slit at the medial aspect of the kidney; which transmits blood
vessels, nerves and ureter.
• Renal coverings:
 Renal fascia: collection of connective tissue that lie outside perirenal fat
 Perirenal fats: covers the fibrous capsule
 fibrous capsule: "true capsule"; surrounds the kidney
• Pararenal fascia- more external to renal fascia
• Gross structural anatomy:
o Cortex, medulla, pyramids, papillae, columns, medullary rays, renal pelvis, major
and minor calyces
• Microscopic anatomical structure
o Nephron
 renal corpuscle- compose of tightly bound capillary network; covered by
bowman's capsule
 renal tubule

• Blood supply: Renal artery


• Renal veins drains into the inf. vena cava
• Lymphatic drainage: para-aortic nodes

The ureter
• 10 in long muscular tube that extends from kidneys to post. wall of the bladder
• 3 physiologic constrictions:
o ureteropelvic jxn
o as it crosses the pelvic brim
o uretero pelvic junction
• 3 divisions:
o abdominal ureter
o pelvic ureter
o intravesical ureter
• 3 blood supply:
o renal atery- supplies the abdominal ureter
o testiculo-ovarian artery- supplies the pelvic ureter
o superior vesical artery- supplies the intravesical ureter
• Lymphatic drainage: iliac and lateral aortic nodes

The bladder
• receptacle for the storage of urine
• lies behind the pubic bones
• has a maximum capacity of 500ml; conscious desire to urinate at 150 ml
• empty bladder lies in the pelvis, as it fills it rises into the hypogastric region
• has strong muscular wall able to hold 750 to 1000ml
• apex- points anteriorly and immediately behind the upper margin of s.pubis
• base: faces posteriorly; ureters join the bladder at its superolateral angles
• superior surface- covered by peritoneum and related to coils of SI
• inferolateral surface- lie in contact with obturator internus(above) and levator
ani(below)
• neck- rest on the upper surface of prostate in males
• lymphatics: int and ext iliac nodes
• bld supply:superior and inferior vesical artery
• Venous drainage: vesical venous plexus--> internal iliac vein
• nerve supply: inferior hypogastric plexusThe circular component of the muscle coat
condenses as an (involuntary) internal urethral sphincter around the internal orifice. This
can be destroyed without incontinence providing the external sphincter remains intact (as
occurs in prostatectomy).

The urethra
Male urethra
• 8in (20cm) long
• divided into:
o prostatic urethra- 1.25 in ling, traverses the prostate
o membranous urethra- 0.75 in long; pierces the external sphincter urethra
o spongy urethra- traverses the corpus spongiosum of the penis
Female urethra
• 1.5in (4cm) long; it traverses the sphincter urethrae
• lies immediately in front of, indeed embedded in the wall of, the vagina
• external meatus opens 1in (2.5cm) behind the clitoris.
2 sphincters:
Internal:
• involuntary
• stretch receptors transmits impulse to brain once urine volume reaches 300ml
• located at the bladder neck
External:
• voluntary
• located on the terminal portion of urethra
Renal physiology:
Urine formation:
• Glomerular filtration
o filtration of blood occurs in the glomerulus. Fluid, electrolytes and other
substances are filtered out of the blood. The process requires adequate
amount of blood and blood pressure
• Tubular reabsorption
o reabsorption of water, glucose and important ions into the blood occurs
primarlly in the PCT, LOH, and DCT. it reclaims the important substances
needed by the body.(Na, K, Cl, HCO3)
• Tubular secretion
o occurs primarily in DCT; secretion of ions, nitrogenous waste, and drugs.
Substances move from the blood to the filtrate.
Symptoms related to Voiding
Obstructive
• urgency, frequency, hesitancy, intermittency, nocturia, sense of incomplte voiding and weak
urinary stream
• most common cause in men: BPH
• Urethral stricture
Irritative
• Dysuria, frequency, urgency
• imply inflammation of urethra, prostate or bladder
• commonly caused by infection & malignancy in patients w/ symptoms that persist after
treatment with appropriate antibiotics
Urinary Tract Infection (UTI)
exists when pathogenic microorganisms are detected in the urine, urethra, bladder, kidney, or
prostate. In most instances, growth of 105 organisms per milliliter from a properly collected
midstream "clean-catch" urine sample indicates infection. Regardless of symptomatic or
asymptomatic.

(Uropathogens)
 E. Coli (>85%)
- normal commensal of GIT
- most common route E Coli from GIT-->colonized in periurethral meatus--> ascend to the
bladder, urethra or even the kidney.
- Hematogenous route
- Lymphatic route: unknown connection between LN to kidney or the renal parenchyma.
 Salmonella Infection
- px with Typhoid fever, there is bacteremic base. Evidence of pus cell, bacteria in urine exam
as part of the findings of salmonella infection.
- Hematogenous seeding
 Other gm (–) organism such as Klebsiella, Proteus, Pseudomonas.
 S. saprophyticus and E. Coli – more common in young sexually active female.
 most frequent isolates in patients with renal calculi due to their ability to split urea:
- Proteus
- Klebsiella
- Ureaplasma urealyticum
 Organism causing UTI thru hematogenous seeding are:
- S. aureus
- P. aeroginosa
- Salmonella
- Candida
 Hemorrhagic cystitis in children is usually due to viral infxn.
 Most common bacterial contaminants of urine culture:
- Staph. Epidermidis
- Corynebacteria
- Lactobacilli: N. bacterial flora in vagina.
- Gardnerellla vaginalis
- Anaerobic bacteria
*** In px w/ communication from gut to the bladder or urethra or w/ predisposing factors
(catheter, urinary obstruction) - true polymicrobial infxn.
*** Otherwise, consider it as contaminants.

Host defenses (AKA compensatory mechanism)

Antiadherence host defense mech.


 Physical
- Mechanical flushing effect of micturition

Substance that prevents attachment to mucosal cells


 Urinary Ig’s
 Tamm-Horsfall mucoprotein- an oligosaccharide makes mucosa more slimy to
prevent attach

Other Host Defenses in Urinary Tract


 Urine has antibacterial porperties due to its:
- high osmolarity
- acidic pH
- high urea content
- presence of ab's
- presence of Tamm-Horsfall protein
- Oligosaccharides

 Although female has shorter urethra and its closer to anus and vagina, there are host defenses.
- Presence of N. bacterial flora of vagina
- Elderly women are more prone to UTI because of the imbalance on hormone production that
maintains the normal flora.
- After broad spectrum antibiotics tx, normal bacterial flora of the vagina may also be
destroyed.

 Bladder
- flushing effect during normal emptying of the bladder.
- Even if the organisms were able to attach to bladder mucosa, normal sloughing of bladder
mucosal cells are carried out by micturition.
 Ureter
- The opening of the ureter closes due to bladder contraction during micturition. If there is
incompetence of the valve (predisposition to UTI) during bladder contraction, there will be
urine back flow up into the ureter.
- N. peristalsis makes it hard for org to climb up against the continuous flow of urine. in the
occurence of reflux, org will be able to ascend from bladder up to kidneys.
 Kidney
- even if the org were able to reach the kidney, fluid in medulla is hypertonic w/c is not a good
medium for bacteria to multiply.

Predisposing Factors for UTI


 Elderly
- elderly women are more prone than younger women, esp post-menopausal woman. Change
of normal bacterial flora guarding vaginal the meatus.
- Hormonal replacement tx: controversial due to the dev't of hormonal dependent tumors
- Young male with UTI: need to evaluate if there are predisposing factor such as:
Homosexual, unusual sexual practices, HIV infection, uncircumcised penis.
 Sex
- females are more prone due to their short urethra and location.
- male’s prostatic secretion is antibacterial. As they become older, antibacterial property is
reduced, so elderly male and female have equal incidence rate for UTI.

 Urinary Tract Obstruction/ Stasis


- Enlargement of prostate causes obstruction of bladder neck.
- Intraluminal/ extraluminal obstruction 2’ to stones obstructing the ureter will predispose to
poor host defenses.
 Vesico ureteral efflux
- Reflux of the urine from bladder reaching the ureter or even the pelvic
 Pregnancy
- During pregnancy, there is a generalized smooth muscle relaxation causing poor peristalsis
which predispose them to infection
- Enlarging uterus compresses the bladder as well as ureter leading to infection
 Neurogenic Bladder
- Always predisposed to UTI
 Indwelling urinary catheter
- acting as a foreign body and also predisposes to infection
 Urinary tract abN
- eg. Horse-shoe shaped kidney or polycystic kidney or any cystic dse
 Instrumentation
- Cystoscopy or Ureteroscopy may introduce bacteria during the procedure.
- Give prophylactic antimicrobials before operation to prevent infection.

Signs and symptoms of UTI


LUTI
 dysuria, frequency, urgency, hematuria or hypogastric pain
 no fever since its only mucosa or superficial
 negative kidney punch

UUTI
 may or may not have signs and symptoms of LUTI
 most prominent sign is fever
 Tissue invasion, stimulating proliferation of leukocyte; therefore, dev leukocytosis and hence
manifested as fever
 PE: Positive kidney punch (costovertebral angle tenderness)

Lab Dx
Urinalysis
Pyuria
 can be detected only by urinalysis
 urine cytometer method: >10 leukocytes/ mm3 is significant
 Direct microscopic exam of urinary sediment
- can be done with routine urinalysis
- >10 leukocytes count is significant
 Urine dipstick for presence of leukocyte esterase
- Change color from white to violet/ pinkish

Bacteriuria
 Direct Microscopy
 Gram’s stain of the urinary sediment
 Chemical test
•Nitrate production test (dipstick)
• Color change due to the conversion of nitrite to nitrate
 Significant Bacteriuria is >100,000 CFU

8 clinical Syndromes of UTI


I. Acute Uncomplicated cystitis in non-pregnant woman
Suspected in non-pregnant women (18-64 years old)
Dysuria, frequency, or gross hematuria, with or without back pain
The following risk factors for Complicated UTI should be absent:
• Hospital acquired infection
• Indwelling urinary catheter
• Recent urinary tract infection
• Recent urinary tract instrumentation (in the past 2 weeks)
• Functional or anatomic abnormality of the urinary tract
• Recent antimicrobial use (in the past 2 weeks)
• Symptoms for > 7 days at presentation
• Diabetes mellitus
• Immunosuppression

o Pre-treatment urine C/S, Urine microscopy and dipstick Leukocyte esterase are not
prerequisites for treatment (Grade E).

o Additional symptoms such as vaginal discharge/ vaginal irritation-- Urine microscopy or


dipstick for LE and nitrites to confirm the diagnosis (Grade B).
Treatment
o Antibiotics effective for acute uncomplicated cystitis:

Antimicrobials Dose & Freq Duration •


TMP-SMX 800/160 mg BID 3 days
Ciprofloxacin 250 mg BID 3 days
Ofloxacin 200 mg BID 3 days
Norfloxacin 400 mg BID 3 days
Levofloxacin 250 mg OD 3 days
Gatifloxacin 400 mg Single dose
Nitrofurantoin 100 mg QID 7 days
Cefixime 400 mg OD 3 days
Cefuroxime 125-250 mg BID 3-7 days
Co-amoxiclav 625 mg BID 7 days

Recommended duration of treatment is 3-days except for Nitrofurantoin which is 7 days.

• Ampicillin and amoxicillin should not be used due to because of consistently high rates of
resistance of E.coli to ampicillin and amoxicillin locally (40% to 80%) (Grade E).
• In healthy elderly women presenting with signs and symptoms of acute cystitis, a three
.day course of any of the antibiotics listed above can be used (Grade A).
• Patients whose symptoms worsen or do not improve after 3 days should have a urine
culture and antimicrobials should be changed empirically, pending result of sensitivity
testing (Grade C).
• Patients whose symptoms improved but do not completely resolve after 3 days,
complete 7 day course of the same antimicrobial.
• Pateints whose symptoms failure resolve after 7 days, should be managed as
complicated UTI (Grade D).

II. Acute Uncomplicated Pyelonephritis (AUPN)

 In otherwise healthy women with no clinical or historical evidence of structural or


functional urologic abnormalities.
 Characaterized by:
i. fever (T>38°C)
ii. chills
iii. flank pain
iv. costovertebral angle tenderness
v. nausea and vomiting
vi. with or without signs and symptoms of lower urinary tract infection
 Recommended diagnostic test for AUPN
• Urinalysis- recommended
UA: pyuria (>/ = 5 wbc/hpf of centrifuged urine)
• Gram stain- recommended
• Urine Culture- facilitates cost effective use of antibiotics because of potential serious
sequelae of of inappropriate antibiotic use.
Urine Culture: > 10,000 cfu/ml on urine culture
• Blood culture- are not routinely done; recommended for patients with signs of sepsis w/
any 2 of the following:

 Temp >38oC or <36oC


 Leukopenia (WBC<4,000) or Leukocytosis (WBC>12,000)
 Tachycardia (>90 bpm)
 Tachypnea (>20 cpm or PaCO2 <32 mmhg)
 Hypotension (SBP<90 mmhg or >40 mmhg drop from baseline)

 Radiologic eval'n- not done routinely;


 Done in patients who remains febrile w/in 72 hrs of treatment or when there is
recurrence of symptoms to rule out nephrolithiasis, urinary tract obstruction, renal or
perinephric abscesses or other complications of pyelonephritis (Grade C).
 Refer patients to urologist if work up shows these abnormalities (Grade C).

 Treatment
 Non-pregnant patients with no signs and symptoms of sepsis, who are are likely to
adhere to treatment & return for follow-up treated as Out patients(Grade B).
 Initial parenteral dose of ceftriaxone may be given followed by an oral antibiotic
(Grade B).
 IV antibiotics can be shifted to oral antibiotics once the patient is afebrile and can
tolerate oral drugs. Choice should be guided by urine culture and sensitivity
results (Grade B).
 The following factors are considered indications for admission (Grade B):
 Inability to maintain oral hydration or take oral medications (eg. Vomiting
patients).
 Concern about adherence to treatment
 Presence of complicating conditions
 Severe illness w/ high fever, severe pain, marked debility and signs of sepsis
 Aminopenicillins & 1st generation cephalosporins are not recommended due to high
prevalence of resistance and increased recurrence rates (Grade C).
 TMP-SMX- not given for empiric treatment due high resistance rates and should used
only when the org is susceptible on urine culture and sensitivity (Grade E).
 Recommended duration of treatment is 14 days. Selected fluoroquinolones can
be given for 7-10 days (Grade A).
 Empiric treatment regimens for uncomplicated acute pyelonephritis
 Antibiotic and Dose Frequency and Duration
• ORAL
o Ofloxacin 400 mg BID; 14 days
o Ciprofloxacin 500mg BID; 7-10days
o Gatifloxacin 400 mg OD; 7-10 days
o Levofloxacin 250 mg OD; 7-10 days
o Cefixime 400 mg OD; 14 days
o Cefuroxime 500 mg BID; 14 days
o Amoxicillin-clavulanate 625 mg (when gram stain
o shows gram positive organisms) TID; 14 days
 PARENTERAL (given until patient is afebrile)
o Ceftriaxone 1-2gm Q 24
o Ciprofloxacin 200-400mg Q 12
o Levofloxacin 250-500 mg Q 24
o Gatifloxacin 400 mg Q 24
o Gentamicin 3-5 mg/kg BW (+/-ampicillin) Q 24
o Ampi-sulbactam 1.5 gm (if with gram positive
o organisms on gram stain) Q6
o Piperacillin- tazobactam 2.25 – 4.5 gm Q6-8

 Clinically responding patients (usually apparent in 72 hours after initiation) a follow up


urine culture is not necessary (Grade C).
 Post treatment urine cultures in clinically improved patients are also not recommended
(Grade C).
 In women whose symptoms do not improve during therapy and in those whose
symptoms recur after therapy
o repeat Urine C/S is recommended (Grade C)
 Duration of treatment in the absence of urologic abnormalities is 2 weeks (Grade C).
 If symptoms recur and culture shows same org as the initial infecting org: 4-6 wks
regimen is recommended (Grade C).

III. Asymptomatic Bacteriuria

 Defined as the presence of > 100,000 cfu/ml of one or more uropathogens in 2


consecutive midstream urine specimens or in one catheterized urine specimen in the
absence of symptoms attributable to urinary tract infection.

 Consider screening and treatment in the following:


 Patients who will undergo genitourinary manipulation or instrumentation(Grade B)
 Post-renal transplant patients up to the first 6 months(Grade B)
 DM pateints with poor glycemic control, autonomic neuropathy or azotemia(Grade C)
 All Pregnant women (Grade A)

 A 7- to 14-day course of any antibiotics used for acute uncomplicated cystitis can be used
(Grade C)
 Screeing and treatment is not recommended in the following group

 Pxs with DM with adequate glycemic control, no autonomic neuropathy or


azotemia(Grade E)
 Elderly patients(Grade D)
 Pxs with indwelling catheters(Grade E)
 Immunocompromised patients(Grade C)
 Solid organ transplant patients(Grade C)
 HIV patients(Grade C)
 Spinal cord injury patients(Grade D)
 Pxs w/ urological abnormalities (Grade C).
 Optimal screening test for ASB

 Urine culture- recommended screening test; (Grade A).


 If not available:
 Urinalysis- pyuria (>10 wbc/hpf); (Grade C)
 Gram stain- positive gram stain of unspun urine (>2 microorganism/oif) in 2
consecutive midstream urine samples; (Grade C)
 Urine C/S- are not done when urinalysis is negative for pyuria or gram stain is
negative for organisms (Grade B).

 Acute Urethral Syndrome


 Signs and symptoms of LUTI but no significant finding from urinalysis
 more common in female
 rule out vaginal infxn (Vaginitis)

IV. Urinary Tract Infection in Pregnancy


(a) Asymptomatic Bacteriuria
 Presence of > 100,000 cfu/ml of one or more uropathogens in 2 consecutive midstream
urine specimens or one catheterized urine specimen, in the absence of symptoms
attributable to a urinary tract infection.
 if 2 consecutive urine cultures are not feasible; 1 urine C/S is acceptable alternative for
diagnosis of ASB in pregnancy. (Grade C)
 All pregnant patient must be screened for ASB on their first prenatal visit(bet. 9-17th
wks) preferably on the 16th wks AOG(Grade A).
 Urine culture- optimal screening for asymptomatic bacteriuria(Grade A).
 If not available, Gram stain of centrifuged urine (cut-off: >6-12/ hpf of same morphology).
 If positive is followed by UA to determine pyuria (>5wbc/hpf) suggest ASB(Grade C).
 Dispstick test for leukocyte esterase and / or nitrite test are not recommended screening test
for ASB in pregnancy (Grade E).
 Urinalysis is not recommended screening test (Grade E).

Treatment
 Indicated to reduce the risk that asymptomatic could become symptomatic (acute cystitis or
acute pyelonephritis) as well as to reduce the risk of prematurity or LBW infant.
 Antibiotics is being initiated upon diagnosis
 Drug: Nitrofurantoin(not for near term)
Amoxiclav,cephalexin and Co-trimoxazole(NEVER in the 1st & 3rd trimester)
 Duration of treatment: 7 days(Grade C)
 Follow-up culture is needed after completion of treatment to detect any relapse (Grade C).

(b) Acute Cystitis in Pregnancy


 Characterized by frequency, urgency, dysuria and bacteriuria but not by fever and
costovertebral angle tenderness. Gross hematuria may also be present
 Pre-treatment diagnostic test
 Urine C/S test of a midstream clean catch urine specimen (Grade C).
 If not available: do urinalysis.
 Pyuria defined as >/= 8 pus cells/mm3 of uncentrifuged urine
>/= 5 pus cells/hpf of centrifuged urine
 (+)leukocyte esterase and nitrite test(Grade C)
 A 7- day course of treatment is recommended;
 Give Empiric antibiotics against organism that are proven safe to give during
pregnancy(Grade A).
 TMP-SMX and fluoroquinolones - potential teratogenicity and the third trimester risk of
kernicterus with TMP-SMX.
 Adjust antibiotic therapy based on Urine C/S results(Grade C).
 Post-treatment urine culture should be obtained to confirm eradication of bacteriuria and
resilution of infection in pregnant women (Grade C).

(c) Acute Pyelonephritis in Pregnancy


 Characterized by:
 shaking chills,
 fever (T>38 C),
 flank pain,
 nausea and vomiting,
 CVA tenderness,
 pyuria of > 5 wbc/hpf of centrifuged urine
 bacteriuria of > 10,000 cfu /ml
 +/- signs and symptoms of LUTI

 Diagnostic test
 Gram stain of uncentrifuged urine is recommended to differentiate gram (+) from
gram (-) which can guide the choice of empiric antibiotic treatment (Grade B).
 Urine culture and sensitivity should be performed routinely to guide the choice of
antimicrobial agents because of the potential for serious sequelae of inappropriate
antimicrobial therapy(Grade B).
 Blood cultures are not routinely recommended for pregnant patients with Acute
pyelonephritis (Grade D).

 Treatment
 Recommended duration of treatment is 10-14 days(Grade B).
 Pregnant patients with signs and symptoms of APN should be hospitalized and
immediate antimicrobial therapy instituted(Grade B).
 Pregnant patients with no signs and symptoms of sepsis and able to tolerate oral
meds- outpatient therapy(Grade B).
 Antibiotics for acute uncomplicated pyelonephritis can be used.
 Fluoroquinolones and aminoglycosides- contraindicated(Grade B).
 In the absence of urine C/S, empiric choice of antibiotic should be based on local
susceptibility patterns of uropathogens(Grade C).
 Post treatment urine culture should be obtained to confirm resolution of
infection(Grade C).
 Patients should be monitored in intervals until delivery to confirm continued urine
sterility during pregnancy

V. Recurrent Urinary Tract Infxn (RUTI)


 Diagnosed when a non preganant woman with no known urinary tract abnormalities
hasEpisodes of acute uncomplicated cystitis documented by urine culture occurring
more than twice times a year
 Prophylaxis is recommended in women whose frequency of recurrence is not acceptable in
terms of level of discomfort or interference with activities of daily living(Grade C).
 withheld according to patient preference if the frequency of recurrence is
tolerable(Grade C).
 Treatment
 Antibiotic prophylaxis
 Regimens recommended:
 continuous- daily intake of a low dose of antibiotic for 6-12 mos(Grade A).
 post-coital prophylaxis- defined as the intake of single dose antibiotic
immediately after intercourse(Grade A).

 given either continuously or post-coital prophylaxis(Grade A).

 Hormonal treatments in post-menopausal women.


 intravaginal estriol creams once/ night x 2 wks ffd by 2x/wk x 8mos. (Grade A).
 Vaccines- no evidence to recommend immuno-reactive E.coli (Grade C).

Diagnostic work-ups
 Routine screening for urologic abnormalities is not recommended for women with
recurrent UTI(Grade E).
 Screening is recommended for patients with(Grade C):
 gross hematuria during a UTI episode
 obstructive symptoms
 clinical impression of persistent infection
 infection with urea-splitting bacteria
 history of pyelonephritis
 history of or symptoms suggestive of urolithiasis
 history of childhood UTI
 elevated serum creatinine
 Choice of screening modalities: plain abdominal rediograph + renal UTZ(Grade B).
 Patients with abnormalities should be referred to a nephrologist and/or urologist(Grade
C).
Treatment
 Any antibiotics for AUC may be used(Grade B).

VI. Complicated UTI


 Significant bacteriuria, which occurs in the setting of functional or anatomic abnormalities of
the urinary tract or kidneys.
 Cut-off set at 100,000 cfu/ml but low-level bacteriuria or counts < 100,000 cfu/ml may be
significant as in catheterized patients

 Conditions that define complicated UTI


 Presence of an indwelling urinary catheter or intermittent catheterization
 Incomplete emptying of the bladder with >100 ml retained urine post-voiding
 Obstructive uropathy due to bladder outlet obstruction, calculus and other causes
 Vesicoureteral reflux & other urologic abnormalities including surgically created
abnormalities
 Azotemia due to intrinsic renal disease
 Renal transplantation
 Diabetes mellitus
 Immunosuppressive conditions – e.g. febrile neutropenia; HIV/AIDS
 UTI caused by unusual pathogens or drug-resistant pathogens
 UTI in males except in young males presenting with exclusively with lower UTI
symptoms

 Diagnostic work up
 Urine GS (Grade B)
 Urine C/S(Grade B)
 Indication for hospitalization
 marked debility and signs of sepsis(Grade C)
 uncertainty in diagnosis(Grade C)
 concern about adherence to treatment(Grade C)
 unable to maintain oral hydration or take oral medications(Grade C)

 Treatment
 mild to moderate illness- oral fluoroquinolones(Grade A)
 severely ill patients- parenteral broad-spectrum antibiotics should be used
 Recommended duration of treatment is at least 7-14 days of therapy(Grade B).
 Duration and type of antibiotics- modified according to the results of the urine C/S.
 Patients started with parenteral regimen may be switched to oral therapy upon clinical
improvement.
Antibiotics that may be used as empiric therapy for complicated UTI
 Oral Regimen
 Ciprofloxacin 250 -500 mg BID x 14 days
 Norfloxacin 400 mg BID x 14 days
 Ofloxacin 200 mg BID x 14 days
 Levofloxacin 250-500 mg OD x 10-14 days
 Parenteral Regimen
 Ampicillin 1 gm q 6hrs + gentamicin 3 mg/kg/day q 24h
 Ampicillin-sulbactam 1.5 gm to 3 gm q 6h
 Ceftazidime 1-2 gm q 8h
 Ceftriaxone 1-2 gm q 24h
 Imipenem-cilastin 250-500 mg q 6-8 h
 Piperacillin-Tazobactam 2.25 gm q 6
 Ciprofloxacin 200-400 mg q 12hrs
 Ofloxacin 200-400 mg q 12h IV
 Levofloxacin 500 mg q 24h IV

Post-treatment urine culture


 Done 1-2 weeks after completion of medications(Grade C).
 If significant bacteriuria persists- referral to specialties(Grade C).

 UTI in DM patients
 requires pre-treatment urine GS, culture and a post-treatment urine culture.
 At least 7-14 days of oral antibiotics is recommended that achieves high
concentrations both in urine and urinary tract tissues.
 Diabetic patients who presents with signs of sepsis should be hospitalized.
 Urine and blood cultures prior to initiation of antibiotic therapy are indicated.
 Failure to respond within 48-72 hours warrants a plain radiograph of KUB, a
renal UTZ, or a CT-scan (Grade C).
 UTI in HIV/ AIDS Patients
 Patients should be evaluated to include other non-bacterial pathogens if
clinically suspected and should be referred to an infectious disease specialist
(Grade C).
 Urinary Candidiasis
 Candiduria is defined as the presence of candida species regardless of the
colony count in properly collected urine specimens on two separate
occasions at least 2 days apart.
 Treatment of asymptomatic and minimally symptomatic candiduria is not
recommended because it does not provide clear clinical benefit such as long
term eradication (Grade D).
 UTI in renal transplant patients
 UTI which develops on the first three months post-transplant
 Treated with broad-spectrum antibiotics until urine culture becomes negative-->
shifted to oral agents according to urine culture and sensitivity results and
continued to complete for 4-6 weeks (Grade c).
 UTI after the first 3 months post-transplant with no evidence of sepsis --> treat
as out-patient.
VII. Catheter-Associated UTI
 Catheterized patients with significant bacteriuria of > 100 cfu/ml of urine, who develop
signs and symptoms of UTI or fever or other signs of bacteremia (Grade B).
 Consider antibiotic treatment in the ff subset of catheterized px who have bacteriuria but
assymptomatic (Grade C):
 those with org that cause high incidence of bacteremia in their instituion
 post solid organ transplant
 those who will undergo urologic procedures
 neutropenic patient
 pregnant patient
 Who may be a part of an infection control plan to manage cluster of infections
in a unit
 Indwelling catheters should be removed to help eradicate bacteriuria (Grade A).
 Long term indwelling catheters should be replaced with new catheters before initiating
antibiotic therapy for asymptomatic UTI (Grade A).

VIII. UTI in Men


A. UNCOMPLICATED CYSTITIS IN YOUNG MEN
 Generally considered complicated.
 However, the first episode of symptomatic lower UTI occurring in a young (15-40 y.o.)
healthy sexually active men with no clinical or historical evidence of a structural or
functional urologic abnormality is considered as uncomplicated UTI.
Diagnostic work-up
 Urinalysis & Urine Culture
o Significant pyuria in men is defined as > 10 wbc/mm3 (CBC) or > 5 wbc/hpf in a
clean catch midstream urine specimen. This shows good correlation with
bladder bacteriuria and the growth of > 1,000 colonies of one predominant
species / ml of urine and best differentiates sterile from infected bladder
urine(Grade C).
 Pre-treatment urine culture should performed routinely in all men with UTI(Grade C).
 Routine urologic evaluation and use of imaging procedures are not recommended(Grade
C).

Treatment
Seven-day antibiotic regimens are recommended.
TMP-SMX or fluoroquinolones may be used depending on prevailing susceptibility patterns in
the community or institution

B. PROSTATITIS SYNDROMES

Category Characteristic
I Acute bacterial Acute infection of the prostate gland characterized by fever,
prostatitis chills, low back pain and perineal pain. Irritative voiding
symptoms (dysuria, frequency, urgency, nocturia) are
characteristic. Rectal examination reveals a markedly tender,
swollen prostate.

II Chronic Recurrent infection of the prostate caused by persistence of the


bacterial prostatitis same organism despite treatment. Symptoms are irritative
voiding & pain of varying degrees. Rectal examination reveals no
characteristic finding.
III Chronic No demonstrable infection; primarily pain complaints, plus
prostatitis / chronic voiding complaints and sexual dysfunction affecting men of all
pelvic ages. Usually cause is unknown.
pain syndrome
(CP/CPPS)
IIIA Inflammatory Symptomatic patients without bacteriuria but with inflammation
subtype (white cells) in semen, expressed prostatic secretions (EPS) or
post-prostatic massage urine

IIIB Non- No white cells in semen, EPS or post-prostatic massage urine


inflammatory
subtype
IV Asymptomatic No subjective symptoms, inflammation detected either by
inflammatory prostate biopsy or the presence of white cells in expressed
prostatitis prostatic secretions or semen during evaluation of other
genitourinary complaints

Diagnostic work-up
 DRE
 Transrectal ultrasound
 Seminal fluid analysis-recommended for the presumptive diagnosis of prostatitis (all
types), whether acute or chronic.

 Acute bacterial prostatitis


o Mid-stream urine for dipstick testing, culture for bacteria, and antibiotic sensitivity are
recommended(Grade C).
o Prostatic massage should not be performed on patients with acute bacterial
prostatitis since this would be extremely painful, could precipitate bacteremia
 Chronic bacterial prostatitis
o lower urinary tract localization procedure is recommended(Grade C).
 Procedure
1. Voided bladder 1 (VB1) Initial 5–10 mL of urinary stream
2. Voided bladder 2 (VB2) Midstream specimen
3. Expressed prostatic secretions (EPS)- expressed from prostate by digital massage after
midstream specimen
4. Voided bladder 3 (VB3) First 5–10 mL of urinary stream immediately after prostate
massage
o Unequivocal diagnosis of chronic bacterial prostatitis requires a 10-fold higher
concentration of a uropathogen in the VB3 of EPS specimen when compared to the
VB1 specimen. The organism is identical to organisms causing repeated episodes of
bacteriuria.
Treatment
a. Acute bacterial prostatitis - empirical therapy with TMP/SMX or an oral fluoroquinolone may
be started until C/S results are known(Grade C).
Adequate hydration should be maintained, rest encouraged, and analgesics such as NSAIDs
used(Grade C).

Treatment should extend to at least 30 days to prevent the development of chronic


prostatitis(Grade C).

Quinolone or aminoglycoside-penicillin derivative comb'n- given for 30 days in severely ill


patients(Grade C).

If there is no response within the first week, change the antimicrobial and do culture of EPS(Grade
C).

Inadequately treated acute bacterial prostatitis will cause complication  Chronic bacterial
prostatitis

b. Chronic bacterial prostatitis

Treatment should be guided by antimicrobial susceptibility patterns.

For chronic bacterial prostatitis, first of line treatment is a quinolone such as:
• Ciprofloxacin 500 mg BID for 28 days(Grade C).
• Ofloxacin 200 mg BID for 28 days (Grade C)
• Norfloxacin 400 mg BID for 28 days (Grade C)

For those allergic to quinolones, the following are recommended:


• Doxycycline 100 mg BID for 28 days (Grade C)
• Minocycline 100 mg BID for 28 days(Grade C)
• Trimethoprim 200 mg BID daily for 28 days(Grade C)
• TMP-SMX 160/800 mg BID for 28 days(Grade C)

Radical transurethral resection of the prostate or total prostatectomy- for men with
recalcitrant chronic bacterial prostatitis
For symptomatic relief, Sitz baths, anti- inflammatory agents, prostatic massage and other
supportive measures can be given(Grade C).
Long-term, low-dose suppressive therapy may be required for patients who do
not respond to full dose treatment. TMP-SMX 80/400 mg once daily is recommended for 4 to
6 weeks(Grade C)

c. Chronic prostatitis / Chronic pelvic pain syndrome (CP/CPPS)

Antibiotics or alpha-adrenergic blockers are not recommended for refractory or long-standing


CP/CPPS(Grade D).

Heat treatment may be useful to relieve chronic pelvic pain syndrome (Grade C).