Urinary Tract Infection - Clinicals, Diagnosis, and Management

Nephrology

Clinicals - History

Fact Explanation
Spectrum of presentation of urinary tract infection (UTI). Infection of the urinary tract may lead to development of acute pyelonephritis, acute cystitis/urethritis, acute prostatitis, septicaemia and asymptomatic bacteriuria. UTI is diagnosed when more than 10 to the power 5 organisms/ ml is found in midstream urine. Spectrum of presentation of urinary tract infection (UTI).
Infection of the urinary tract may lead to development of acute pyelonephritis, acute cystitis/urethritis, acute prostatitis, septicaemia and asymptomatic bacteriuria. UTI is diagnosed when more than 10 to the power 5 organisms/ ml is found in midstream urine.
Frequency Increased frequency of micturition is a symptom of lower tract infection. Frequency
Increased frequency of micturition is a symptom of lower tract infection.
Dysuria Burning sensation during passage of urine through the urethra is a symptom of urethritis. Dysuria
Burning sensation during passage of urine through the urethra is a symptom of urethritis.
Urgency Is a symptom of cystitis/ urethritis due to spasm of the inflamed bladder wall. Urgency
Is a symptom of cystitis/ urethritis due to spasm of the inflamed bladder wall.
Abdominal pain The patient may experience suprapubic pain in acute cystitis. Loin pain characteristically occurs in acute pyelonephritis. Abdominal pain
The patient may experience suprapubic pain in acute cystitis. Loin pain characteristically occurs in acute pyelonephritis.
Fever Systemic symptoms are usually mild in lower tract infections. Fever with chills & rigors are prominent symptoms of acute pyelonephritis. Fever
Systemic symptoms are usually mild in lower tract infections. Fever with chills & rigors are prominent symptoms of acute pyelonephritis.
Asymptomatic bacteriuria Presence of more than 10 to the power 5 organisms/ ml in the urine of an asymptomatic healthy patient. Asymptomatic bacteriuria
Presence of more than 10 to the power 5 organisms/ ml in the urine of an asymptomatic healthy patient.
Look for risk factors for UTI Factors which lead to incomplete bladder emptying such as bladder outflow obstruction, uterine prolapse, neurogenic bladder (spinal cord dysfunction/multiple sclerosis) predispose to UTI. UTI is common in diabetic and immunocompromised patients. Urethral instrumentation may also introduce organisms into the urinary tract. Look for risk factors for UTI
Factors which lead to incomplete bladder emptying such as bladder outflow obstruction, uterine prolapse, neurogenic bladder (spinal cord dysfunction/multiple sclerosis) predispose to UTI. UTI is common in diabetic and immunocompromised patients. Urethral instrumentation may also introduce organisms into the urinary tract.

Clinicals - Examination

Fact Explanation
General examination : Fever Fever is mild in cystitis/ urethritis while is a prominent feature in acute pyelonephritis. Patients with acute pyelonephritis appear very ill. General examination : Fever
Fever is mild in cystitis/ urethritis while is a prominent feature in acute pyelonephritis. Patients with acute pyelonephritis appear very ill.
Cardiovascular examination : Hypo tension & tachycardia May be present in patient who develop septicaemia. Cardiovascular examination : Hypo tension & tachycardia
May be present in patient who develop septicaemia.
Abdominal examination Patients with acute cystitis will have suprapubic tenderness. Patients with acute pyelonephritis will have renal angle tenderness and guarding in the lumbar region. A palpable bladder may be felt in patients with chronic urinary retention. Abdominal examination
Patients with acute cystitis will have suprapubic tenderness. Patients with acute pyelonephritis will have renal angle tenderness and guarding in the lumbar region. A palpable bladder may be felt in patients with chronic urinary retention.
Rectal examination Benign prostatic hypertrophy may be detected in an elderly male. Rectal examination may also be performed in males patients suspected with prostatitis to detect prostatic tenderness. Rectal examination
Benign prostatic hypertrophy may be detected in an elderly male. Rectal examination may also be performed in males patients suspected with prostatitis to detect prostatic tenderness.
Vaginal examination To exclude uterine prolapse which is a risk factor for UTI. Vaginal examination
To exclude uterine prolapse which is a risk factor for UTI.
Assessment for risk factors Examine the spine for congenital anomalies or acquired conditions - Spinal injury. Perform neurological examination in suspected patients with multiple sclerosis, diabetic neuropathy which may lead to neurogenic bladder. Assessment for risk factors
Examine the spine for congenital anomalies or acquired conditions - Spinal injury. Perform neurological examination in suspected patients with multiple sclerosis, diabetic neuropathy which may lead to neurogenic bladder.

Investigations - Diagnosis

Fact Explanation
Urinalysis Samples which could be taken are mid-stream urine and s. Microscopy and culture help identify the causative pathogen. A significant result is decided according to bacterial counts. Presence of any number of organisms in a supra-pubic aspiration is significant. In a symptomatic patient with neutrophils in urine, a small number of organisms is significant. Urinalysis
Samples which could be taken are mid-stream urine and s. Microscopy and culture help identify the causative pathogen. A significant result is decided according to bacterial counts. Presence of any number of organisms in a supra-pubic aspiration is significant. In a symptomatic patient with neutrophils in urine, a small number of organisms is significant.
Urinalysis - cytometry Presence of pus cells in urine support the diagnosis of UTI. Microscopic haematuria may be detected. Urinalysis - cytometry
Presence of pus cells in urine support the diagnosis of UTI. Microscopic haematuria may be detected.
Urine dipstick testing Urine dipstick testing can be done for nitrites and leucocyte esterase. Presence of either supports a diagnosis of UTI. Urine dipstick testing
Urine dipstick testing can be done for nitrites and leucocyte esterase. Presence of either supports a diagnosis of UTI.
Blood culture Blood culture may be indicated if the patient presents with high fever with rigors or evidence of septic shock. Blood culture
Blood culture may be indicated if the patient presents with high fever with rigors or evidence of septic shock.

Investigations - Management

Fact Explanation
Renal ultrasound scan/ CT scan Imaging of the kidneys are used to rule out calculi, obstruction, cysts etc which may be the cause of UTI. Follow up imaging studies are required after a single episode of UTI in male patients. In females USS is used in complicated UTIs (acute pyelonephritis, recurrent UTI, failure to respond to treatment, UTI in pregnancy etc). Renal ultrasound scan/ CT scan
Imaging of the kidneys are used to rule out calculi, obstruction, cysts etc which may be the cause of UTI. Follow up imaging studies are required after a single episode of UTI in male patients. In females USS is used in complicated UTIs (acute pyelonephritis, recurrent UTI, failure to respond to treatment, UTI in pregnancy etc).
Intravenous urogram (IVU) IVU is particularly useful to observe the lumen of the collecting system, ureters and bladder. Lesions will be demonstrated as a filling defect. It is indicated to to exclude the possibility of urothelial malignancies, calculi and abnormalities of renal papillae. Intravenous urogram (IVU)
IVU is particularly useful to observe the lumen of the collecting system, ureters and bladder. Lesions will be demonstrated as a filling defect. It is indicated to to exclude the possibility of urothelial malignancies, calculi and abnormalities of renal papillae.
Cystoscopy Cystoscopy is indicated when the patient presents with haematuria. Bladder carcinoma which presents with painless haematuria may predispose to recurrent UTIs. Cystoscopy
Cystoscopy is indicated when the patient presents with haematuria. Bladder carcinoma which presents with painless haematuria may predispose to recurrent UTIs.
Full blood count Neutrophilic leucocytosis will be seen due to infection. Blood picture will reveal immature white blood cells(left shift) Full blood count
Neutrophilic leucocytosis will be seen due to infection. Blood picture will reveal immature white blood cells(left shift)
plasma urea, creatinine, electrolytes For assessment of renal function particularly in recurrent UTI, acute pyelonephritis etc. plasma urea, creatinine, electrolytes
For assessment of renal function particularly in recurrent UTI, acute pyelonephritis etc.

Management - Supportive

Fact Explanation
Patient education Information should be provided to the patient regarding the natural course of the illness, complications, treatment available and follow-up investigations. Patient education
Information should be provided to the patient regarding the natural course of the illness, complications, treatment available and follow-up investigations.
Maintain adequate fluid intake A minimum fluid intake of 2 liters per day is recommended. Maintain adequate fluid intake
A minimum fluid intake of 2 liters per day is recommended.
Symptomatic treatment The fever may be controlled with anti-pyretics. There is limited evidence for use of potassium citrate to treat dysuria. Symptomatic treatment
The fever may be controlled with anti-pyretics. There is limited evidence for use of potassium citrate to treat dysuria.

Management - Specific

Fact Explanation
Treatment of cystitis/ urethritis A 3 day oral antibiotic regime is considered adequate. Uncomplicated UTI in females may be even treated without urine culture testing. Trimethoprim is the first line treatment (200mg daily).Other antibiotics that can be used are Nitrofurantoin(50 mg 6-hourly), Ciprofloxacin(100 mg 12-hourly), cephalexin(500 mg 12-hourly). Co-amoxiclav and amoxicillin can be used if the causative organism is found to be sensitive. Treatment of cystitis/ urethritis
A 3 day oral antibiotic regime is considered adequate. Uncomplicated UTI in females may be even treated without urine culture testing. Trimethoprim is the first line treatment (200mg daily).Other antibiotics that can be used are Nitrofurantoin(50 mg 6-hourly), Ciprofloxacin(100 mg 12-hourly), cephalexin(500 mg 12-hourly). Co-amoxiclav and amoxicillin can be used if the causative organism is found to be sensitive.
Management of acute pyelonephritis Depending on the severity oral or IV antibiotics are used for a period of 7-14 days. In severe cases IV cephalosporin, quinolone or gentamicin may be used. In less severe cases oral antibiotics can be used. Management of acute pyelonephritis
Depending on the severity oral or IV antibiotics are used for a period of 7-14 days. In severe cases IV cephalosporin, quinolone or gentamicin may be used. In less severe cases oral antibiotics can be used.
Management of Acute prostatitis Patients should be treated with either trimethoprim or quinolones (Ciprofloxacin/ norfloxacin) for a duration of 4-6 weeks. Management of Acute prostatitis
Patients should be treated with either trimethoprim or quinolones (Ciprofloxacin/ norfloxacin) for a duration of 4-6 weeks.
Persistent or recurrent UTI Persistent infection and recurrent infection requires investigations to exclude an underlying cause. Men, children and patients with renal damage require prompt investigation while in females recurrent infection is common and investigations are indicated if the episodes are frequent or severe. The patient may be started on prophylactic antibiotic and monitored with routine urine cultures. Persistent or recurrent UTI
Persistent infection and recurrent infection requires investigations to exclude an underlying cause. Men, children and patients with renal damage require prompt investigation while in females recurrent infection is common and investigations are indicated if the episodes are frequent or severe. The patient may be started on prophylactic antibiotic and monitored with routine urine cultures.
Asymptomatic bacteriuria Treatment is usually not required for except when the patient is diagnosed with an abnormality of the urinary tract or if the patient is pregnant. Asymptomatic bacteriuria
Treatment is usually not required for except when the patient is diagnosed with an abnormality of the urinary tract or if the patient is pregnant.
UTI in pregnancy Penicillins and cephalosporins are safe for use during pregnancy. Antibiotics such as trimethoprim, quinolones, tetracyclins should be avoided in pregnancy. UTI in pregnancy
Penicillins and cephalosporins are safe for use during pregnancy. Antibiotics such as trimethoprim, quinolones, tetracyclins should be avoided in pregnancy.

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