Urinary Tract

Infection
PGI FRANCISCO, Maria Ellaine
PGI GALVEZ, Angelo
GENERAL DATA
A.V.
Office worker
24 year old
Female
Single
December 17, 1996
Caloocan City
Catholic Christian
CHIEF COMPLAINT:
Painful urination
HISTORY OF PRESENT ILLNESS
1 day PTC • (+) pain during voiding characterized as burning
• (+) increased frequency of urination
• (+) urinary urgency
• No other symptoms such as fever, flank pain,
nausea and vomiting, blood in urine, and vaginal
discharge
• No medications were taken

• No consult done

Few hours PTC • Persistence of symptoms

REVIEW OF SYSTEMS
General Survey: (-) weight loss, (-) pallor, (-) chills, (-) easy fatigability
Cutaneous: (-) sweating, (-) alopecia, (-) nail clubbing, (-) pruritus
Eyes: (-) blurring of vision, (-) lacrimation, (-) diplopia, (-) photophobia, (-) tearing, (-)
burning sensation, (-) proptosis
Ears: (-) decreased hearing, (-) discharge, (-) tinnitus, (-) otalgia
Nose: (-) anosmia, (-) congestion
Throat and Mouth: (-) bleeding, (-) hoarseness, (-) soreness of throat
Cardiovascular: (-) chest pain, (-) palpitations, (-) orthopnea, (-) PND, (-) edema
Pulmonary: (-) dry cough, (-) colds, (-) shortness of breath, (-) difficulty of breathing
REVIEW OF SYSTEMS
Endocrine: (-) cold intolerance, (-) heat intolerance, (-) polydipsia, (-) polyuria, (-) polyphagia, (-)
sweating

GI: (-) abdominal pain, (-) diarrhea, (-) constipation (-) melena, (-) hematochezia

GU: see HPI

Neurologic: (-) vomiting, (-) headache, (-) dizziness

Hematologic: (-) pallor, (-) easy bruisability, (-) bleeding

PAST MEDICAL HISTORY
● (-) Hypertension
● (-) DM
● (-) PTB
● (-) Asthma
● (-) Cancer
● Previous hospitalizations: None
● Previous operations: None
● Previous blood transfusions: None
● Allergies: No known allergies
● Past Injuries/ accidents: None
FAMILY HISTORY
● (+) Hypertension – Father
● (+) Hypertension - Mother
● (-) Diabetes
● (-) Asthma
● (-) Cancer
● (-) Thyroid disease
PERSONAL AND SOCIAL HISTORY
● Office worker
● Eats 3 meals per day (breakfast, lunch, dinner, and 1-2 snacks in between)
consisting of rice, meat, fish, vegetables and fruits for snacks
● Drinks an average of 8-10 glasses of water per day
● Non-smoker
● Non- alcoholic beverage drinker
● Denies illicit drug use
● Lives in a 2 storey apartment, well- ventilated, well- lit with her family
● No pets, no nearby factories, no exposure to a known PTB case
● Garbage collected thrice a week, not segregated nor recycled
● Water Source is from filtered tap water
Obstetric & Gynecology History
GYNECOLOGIC HISTORY:
- Menarche: 11 years old Nulligravid
- Interval: 28-30 days LMP: November 19, 2020
- Duration: 3-4 days
- Amount: 3-4 moderately soaked pads per day
- Symptoms: none

SEXUAL HISTORY:
- Denies any sexual contact/activities
- Never been in a romantic relationship
Physical Examination
General survey: conscious, coherent, not in cardiopulmonary distress
VS: BP: 110/70mmHg CR: 79 bpm RR: 18cpm Temp: 36.8C O2 Sat: 99%
Ht 157 cm Wt 52 kg BMI: 21.06 (normal)
Skin/Cutaneous: warm, moist skin, (-) jaundice, (-) cyanosis
Head: Symmetrical, no lesion, no mass, no tenderness
Eyes: pink palpebral conjunctivae, anicteric sclerae, transparent cornea, lens are
clear; iris are black with regular contours, pupils are 2-3 mm equally reactive to light
and accommodation.
Ears: Auricles are symmetrical and non-tender; auditory canals are patent, no
discharge; tympanic membrane is pearly white, with visible cone of light.
Nose and Sinuses: septum midline, turbinates are not congested, no discharge, no
tenderness over the frontal and maxillary sinuses.
Mouth and Throat: lips and buccal mucosa are pink and moist, no ulcers, no
exudates, non-hyperemic tonsils
Physical Examination
Neck: supple, symmetrical, no neck vein engorgement, no mass,
trachea in midline, soft, no palpable lymph nodes
Respiratory: Symmetrical chest expansion, no lagging, vesicular
breath sounds, no wheezes and rales
Cardiovascular: Adynamic precordium, apex beat is at the 5th LICS
MCL, normal rate, regular rhythm, no heaves, no thrills, no murmurs
Abdomen: flabby, soft, normoactive bowel sounds, no palpable mass,
liver span 9cm, non palpable spleen, no CVA tenderness, (+)
tenderness on the suprapubic region, tympanitic in all quadrants
Extremities: No gross deformities, full and equal pulses on all
extremities, CRT <2secs, no edema
NEUROLOGIC EXAMINATION
Conscious, coherent, GCS 15 (E4V5M6), oriented to time, place and person.

Cranial Nerves:
CN I: able to identify smell of coffee on both nostrils.
CN II: no visual field defects, (+) ROR, AV ratio 2:3, no hemorrhages, no papilledema.
CN III, IV, & VI: EOMs intact
CN V: can clench the teeth, (+) corneal reflex
CN VII: no facial asymmetry, able to smile, frown
CN VIII: gross hearing intact
CN IX and X: Uvula midline, intact gag reflex
CN XI: Can shrug both shoulders, able to turn head from side to side
CN XII: tongue midline upon protrusion
NEUROLOGIC EXAMINATION
Cerebellum: (-) dysmetria, (-)dysdiadochokinesia, (-) nystagmus
Abnormal reflexes: (-) Babinski
Meningeal signs: (-) Nuchal rigidity, (-) Brudzinski, (-) Kernig’s

Motor: Sensory:
5/5 5/5 100% 100%

100% 100%
5/5 5/5
SALIENT FEATURES
SUBJECTIVE DATA: OBJECTIVE DATA:
● 24 year old • Afebrile
● Female
• Suprapubic tenderness
● Non pregnant, healthy
● CC: painful urination • No CVA tenderness
● 1 day PTC-
⮚ (+) pain during voiding characterized as burning
⮚ (+) increased frequency of urination
⮚ (+) urinary urgency
⮚ No other symptoms such as fever, flank pain,
nausea and vomiting, blood in urine, and vaginal
discharge

● Few hours PTC- persistence of symptoms

● Denies sexual contact
 Patient Acute Uncomplicated Acute Uncomplicated Urethritis
Cystitis Pyelonephritis
● 24 year old ● Female ● Female ● Dysuria
● Female ● Acute onset dysuria ● Acute onset dysuria ● Urinary frequency and
● Non pregnant, healthy
● CC: painful urination
● Urinary frequency and ● Urinary frequency and urgency
● 1 day PTC- urgency urgency ● Suprapubic tenderness
⮚(+) pain during voiding ● Suprapubic tenderness ● Suprapubic tenderness
characterized as burning ● No fever, flank pain,
⮚(+) increased frequency of nausea and vomiting,
urination
⮚(+) urinary urgency gross hematuria
● No vaginal discharge
⮚No other symptoms such
as fever, flank pain,
nausea and vomiting, ● (-)Fever ● (-)discharge from urethral
blood in urine, and vaginal Cannot be totally ruled out ● (-)Chills opening or vagina
discharge ● (-)Flank pain ● (-)Urethral itching
● (-)Costovertebral tenderness
● Few hours PTC- ● (-)Nausea
persistence of symptoms ● (-)Vomiting
● Denies sexual contact

● Afebrile
● Suprapubic tenderness
● No CVA tenderness
 Acute Urinary Tract
INITIAL
Infection Probably Acute
Impression: Uncomplicated Cystitis
 CASE DISCUSSION
Urinary Tract Infection
 UTI
GENERALITIES
Harrison’s Principles of Internal Medicine, 20th Edition
 Urinary Tract Infection
● UTI may be asymptomatic (subclinical infection) or symptomatic (disease).
● Encompasses a variety of clinical entities:
○ Asymptomatic Bacteriuria
○ Cystitis
○ Pyelonephritis
○ Prostatitis

● Both UTI and ASB connote the presence of bacteria in the urinary tract,
usually accompanied by white blood cells and inflammatory cytokines in the
urine.
● However, ASB occurs in the absence of symptoms attributable to the bacteria
in the urinary tract and usually does not require treatment, while UTI has more
typically been assumed to imply symptomatic disease that warrants
antimicrobial therapy.
 Epidemiology
● Except among infants and the elderly, UTI occurs far more
commonly in females than in males.
● During the neonatal period, the incidence of UTI is slightly higher
among males than among females because male infants more
commonly have congenital urinary tract anomalies.
● After 50 years of age, obstruction from prostatic hypertrophy
becomes com­mon in men, and the incidence of UTI is almost as
high among men as among women.
● As many as 50–80% of women in the general population acquire
at least one UTI during their lifetime—uncomplicated cystitis in
most cases.
 General Risk Factors
● History of UTI (20-30% will recur)
● Frequent sexual intercourse
● Urinary incontinence
● Diabetes
● Pregnancy in women
● Prostatic hypertrophy in men
● Uncircumcised men
● Urinary tract abnormalities/instrumentation
 Etiology
● Uncomplicated UTI
○ E.coli (75-90%)
○ S.saprophyticus (5-15%)
○ Others (Klebsiella, Proteus, Enterococcus, Citrobacter sp.)
(5-10%)
● Complicated UTI
○ E.coli –mostly
○ Aerobic Gram (-) Bacteria - P.aeruginosa, Klebsiella,
Proteus, Citrobacter, Acinetobacter, Morganella sp.
○ Gram (+) Bacteria - Enterococci, S.aureus
○ Yeasts
Pathogenesis
 Diagnostic Tools
● History and Physical Exam
○ The diagnosis of any of the UTI syndromes or ASB begins with a detailed
history 
○ At least 1 symptom of UTI without complicating factors is 50% probability
of cystitis or pyelonephritis;
○ If vaginal discharge and complicating factors are absent and risk factors
for UTI are present, then the probability of UTI is close to 90%, and no
laboratory evaluation is needed. 
○ A combination of dysuria and urinary frequency in the absence of vaginal
discharge increases the probability of UTI to 96%. 

● Laboratories
○ Urine dipstick test
○ Urinalysis: Pyuria in nearly all cases (WBC ≥ 5 /hpf), hematuria in 30%,
bacteriuria
○ Urine culture and sensitivity (Gold standard)
DIAGNOSTIC APPROACH
 ACUTE
Uncomplicated
Cystitis
Acute Uncomplicated Cystitis
● The typical symptoms of cystitis are dysuria, urinary frequency, and urgency in a
non-pregnant, healthy premenopausal female.
● Nocturia, hesitancy, suprapubic discomfort, and gross hematuria are often noted
as well.
○ Unilateral back or flank pain is generally an indication that the upper urinary tract is involved.
Fever also is an indication of invasive infection of either the kidney or the prostate. 
● Urinalysis is not necessary to confirm diagnosis if at least 1 symptom above is
present.
● However, if the symptoms are not specific or if a reliable history cannot be
obtained, then a urine dipstick test should be performed. 
● A positive nitrite or leukocyte esterase result in a woman with one symptom of UTI
increases the probability of UTI from 50% to ~80%, and empirical treatment can
be considered without further testing. 
● In women with complicated UTI (e.g., due to pregnancy, suspected bacterial
resistance, or recent UTI), a urine culture is warranted to guide appropriate
therapy. 
Acute Uncomplicated Cystitis
Cystitis in Men 
● Collection of urine for culture is strongly recommended when a man has symptoms of UTI
● In a study of 85 men with febrile UTI, symptoms of urinary retention, early recurrence of UTI,
hematuria at follow-up, and voiding difficulties were predictive of surgically correctable
disorders.  
● In general, men with a first febrile UTI should have imaging performed (CT or ultrasound); 
if the diagnosis is unclear or if UTI is recurrent, referral for urologic consultation 
TREATMENT
 Acute Uncomplicated Cystitis
● Urinalysis is NOT necessary to confirm the diagnosis
● Pre-treatment urine culture and sensitivity is NOT
recommended
● Standard urine microscopy and dipstick leukocyte esterase
(LE) and nitrite test are NOT prequisite for treatment

Empiric antibiotic treatment is the most cost-effective

approach in management of AUC
 Plan for the Patient
Anne Valeentawak 12/17/2020
Caloocan City 24 F
● For pregnancy test
● Advise proper hygiene
● Discourage use of soap prevent disruption
of normal flora Nitrofurantoin macrocrystals 100mg/cap # 20
● Use breathable cotton undergarments
● Advise patient to drink ≥ 3L water daily to
Sig: Take 1 capsule every 6 hours
facilitate unidirectional clearance of
for 5 days
bacteriuria and prevent recurrence
● Practice proper hygiene after intercourse

Ellaine Francisco, MD
 Plan for the Patient
● Follow-up after 5 days
○ Symptoms resolved: no further tests or treatment
○ Symptoms persist: request for urinalysis and shift to
another antibiotic empirically
Acute Uncomplicated
Pyelonephritis
Harrison’s Principles of Internal Medicine, 20th Edition
Acute Uncomplicated Pyelonephritis
● Suspected in otherwise healthy women with no clinical or historical evidence of
anatomic of functional urologic deficiencies or abnormalities
● Commonly presents as
○ Fever of 38C or greater
○ Flank pain
○ CVA tenderness
○ Nausea and vomiting
○ With or without signs and symptoms of lower UTI
● Urinalysis: Pyuria (5 WBC/hpf)
● Urine Culture: Bacteriuria (10000 CFU/mL)
Diagnostic Tests
● Urinalysis and gram staining are recommended
● Urine culture and sensitivity should be performed routinely
● In patients with signs of sepsis, blood culture may be performed
● Biomarkers (procalcitonin, mid-regional pro atrial natriuretic
peptide and C-reactive protein) are not recommended
Indications for Admission
● Inability to maintain oral hydration or take medications
● Inability to comply
● Presence of possible complications
● Severe illness
○ High grade fever
○ Severe pain
○ Severe functional debility
○ Signs of sepsis
Role of Urologic Imaging
● Use of imaging procedures are not
recommended
● Early radiologic evaluation if
○ History of urolithiasis
○ Urine pH 7.0 or greater
○ Renal insufficiency
● Radiologic evaluation is considered:
○ Patient is still febrile after 72 hours of
treatment
○ Recurrence of symsptoms
Antibiotic Treatment
● Quinolones
○ Recommended first line treatment in patients not requiring admission
● Initial single IV/IM dose of ceftriaxone or aminoglycoside
○ May also be considered in patients not requiring admission
● Ceftriaxone, flouroquinolones or aminoglycosides
○ Recommended first-line treatment for patients that require admission
● Ampicillin, amoxicillin or 1st gen cephalosporins
○ Not recommended
Antibiotic Treatment
● Trimethoprim-sulfamethoxazole
○ Not recommended for empiric treatment
○ May be used against susceptible uropathogens
● Ampicillin combined with aminoglycoside
○ Recommended for suspected enterococcal infection
● Carbapenems and piperacillin-tazobactam
○ Reserved for susceptible MDR organisms
 Asymptomatic
Bacteriuria
Harrison’s Principles of Internal Medicine, 20th Edition
Diagnosis
● Asymptomatic
● Urine Culture
○ Men - single voided specimen, 1 bacterial strain >100,000
cfu/mL
○ Women - 2 consecutive voided specimens, same bacterial strain
>100,000 cfu/mL
○ Both - catheterized specimen, 1 bacterial species, >100 cfu/mL
Screening and Treatment
● Urinalysis
○ 2 consecutive midstream samples
■ Significant pyuria (>10WBC/hpf)
■ (+) Gram stain of unspun urin (>2 microorganism/oif)
○ If negative, no need for culture and sensitivity
● Urine culture (Gold Standard)
● Who should be screened and treated?
○ All pregnant women
○ Patients who will undergo GU procedures or manipulation
■ Treatment varies with C&S results
 Recurrent UTI
Harrison’s Principles of Internal Medicine, 20th Edition
Diagnosis
● Healthy, non-pregnant women with no known UT abnormalities
○ (+) 3 or more episodes of acute uncomplicated cystitis within 12 months
○ (+) 2 or more episodes within 6 months
○ Documented by urine culture
● Relapse: Initial organism persists and resurfaces despite adequate treatment
○ Typically within 1-2 weeks since treatment
● Reinfection
○ Different bacterial isolate
○ Same isolate with negative intervening culture
○ Same isolate >2 weeks between infections
Screening for Urologic Abnormalities
● Not recommended for the general population
● Recommended for:
○ No response to therapy or rapid relapse
○ Gross hematuria or persistent microscopic hematuria
○ Symptoms of urinary obstruction/retention
○ Clinical impression of persistent infection
○ Infection with urea-splitting bacteria (Proteus, Morganella,
Providencia)
○ History of pyelonephritis, childhood UTI or urolithiasis
○ Elevated creatinine
Approach
● History and PE
○ Evaluate urogenital anatomy
○ Estrogenization of vaginal tissues
○ Check for prolapse
● Post-void urine retention
● Urinalysis, Urine Culture and Sensitivity
● Renal UTZ, CT Stonogram - if necessary
Treatment
● Individual episodes are managed as acute uncomplicated cystitis
● Intermittent self-administered therapy
● Breakthrough infections
○ Episodes of UTI during a course of prophylaxis
■ Urine C&S
■ Start empiric antibiotics on top of the current prophylaxis
● No evidence
○ Juices (Coconut, cranberry, prune)
○ Oral hydration therapy
Prophylaxis
● If the frequency is an issue to the patient
○ Discomfort
○ Interference with day to day activities
○ Recurrent UTI is not an absolute indication for prophylaxis
● Antibiotic Prophylaxis
○ Offered only if non-antimicrobial strategies have been exhausted
○ Based on patient preference and ability to comply
○ Could be continuous (6-12 mos), post-coital or intermittent (based on
the need)
Non-antibiotic Prophylaxis
● Behavioral modification / Patient Education
○ Antibiotic-sparing prophylaxis
○ Post-defecation and anal cleaning antero-posteriorly
○ Post-coital douche or urination
○ Liberal fluid intake
○ Avoiding tight-fitting underwear
○ Avoiding contraceptives with spermicides
Non-antibiotic Prophylaxis
● Cranberry products
○ No consistent evidence as to the amount, concentration and duration of intake
○ Recommended
■ 300 mL cranberry juice daily
■ 500mg capsules containing 36mg PACs (proanthocyanidins) BID
■ For patients on antibiotic prophylaxis, cranberry capsules may prevent
emergence of TMP, Amoxicillin and Ciprofloxacin restinace in E. coli
● PACs - condensed tannins which prevent adhesion of fimbriated
E.coli to uroepithelial cells
Non-antibiotic Prophylaxis
● Hormonal Treatment for Post-Menopausal Women
○ Intravaginal estriol cream - once a day at night for 2 weeks then twice
weekly for at least 8 months
○ Estradiol-releasing silicone vaginal ring for 3 months
○ NOT RECOMMENDED: Low-dose oral estrogen
● Immunoprophylaxis
○ Immune-active E.coli fractions
○ Short-term: Once daily PO for 3 months
○ Long-term: Once daily PO for 3 months, rest for 3 months, 10 days a
month for 3 months., rest for 3 months
 Complicated UTI
Harrison’s Principles of Internal Medicine, 20th Edition
Conditions Defining Complicated UTI
●Presence of an indwelling urinary catheter or intermittent catheterization
●Incomplete emptying of the bladder with >100 ml retained urine post-
voiding
●Impaired voiding due to neurogenic bladder, cystocoele
●Obstructive uropathy due to bladder outlet obstruction, calculus, urethral
or ureteric strictures, tumors
●Vesicoureteral reflux & other urologic abnormalities including surgically
created abnormalities
●Chemical or radiation injuries of the uroepithelium
●Peri- or post-operative UTI
Conditions Defining Complicated UTI
● Azotemia due to intrinsic renal disease
● Renal transplantation
● Diabetes mellitus
● Immunosuppressive conditions – e.g. febrile neutropenia, HIV-AIDS
● UTI caused by unusual pathogens (M. tuberculosis, Candida spp.)
● UTI caused by antibiotic-resistant or multi-drug resistant organisms
(MDROs)
● UTI in males except in young males presenting exclusively with lower
UTI symptoms
● Urosepsis
Complicated UTI
● Significant bacteriuria and symptoms on top of:
○ Functional or anatomic abnormalities of the urinary
tract and/or kidneys
○ Presence of underlying disease which compromises host
defense mechanisms
○ Any persisting condition that increases the risk of
acquiring infection and/or treatment failure
Approach
1.Urine sampling for gram stain and culture & sensitivity must be done
BEFORE initiating treatment
2.Imaging (CT Scan is preferred) - warranted when structural or anatomic
abnormalities are suspected:
a.Pyelonephritis unresponsive to treatment
b.Severe pyelonephritis in high-risk groups
c.Recurrent UTI in males
Approach
● Hospitalization
○ Admit if:
■ Marked debility and signs of sepsis
■ Uncertain diagnosis
■ Concern about treatment adherence
■ Unable to maintain oral hydration or tolerate oral medications
○ Outpatient if:
■ None of the above
■ Mild to moderate UTI without urosepsis, circulatory and/or
organ failure
Treatment
● Guided by Urine C&S
● Mild to Moderate Illness
○ Empiric oral treatment
■ No risk factors for antibiotic resistance
■ Oral fluoroquinolones or Co-Amoxiclav
● Severe Illness
○ Empiric parenteral treatment
○ Fluoroquinolones are not recommended
○ May step down to oral therapy upon clinical improvement
● Manage other diseases accordingly
Follow Up
● Repeat Urine C&S 1-2 weeks after completion of antibiotic
therapy
● If significant bacteriuria persists - refer to a specialist
 Special Populations
Harrison’s Principles of Internal Medicine, 20th Edition
UTI in Diabetics
● Screening for asymptomatic bacteriuria is NOT
recommended
● If confirmed, manage as complicated UTI
● Admit if with signs of sepsis
○ Urine C&S along with blood culture must be performed
○ Failure to respond to treatment within 72 hours:
■ KUB, Renal UTZ or CT scan
Catheter-Associated UTI
● UTI in patients with indwelling, suprapubic, intermittent
catheterization or those removed within 48 hours
● Urine Culture: At least 10,000 cfu/mL of at least 1 organism
● If possible, remove catheter
○ If not possible, replace
● Start empiric antibiotics for 7 daus
○ Amikacin 15mg/kg q24 hrs - First line
● Risk reduction strategies: Patient/caregiver education, proper
hygiene and sterile handling techniques and timely removal of the
catheter
Renal Abscess
● Suspected in patients with:
○ Upper UTI, hypotension and renal impairment
○ Persistent fever and hypotension 72 hrs after IV antibiotics
● Imaging: CT Scan
● Cultures: Urine, blood and aspirate if possible
● Antibiotics: Manage as complicated UTI for 4-10 weeks
● Surgical intervention:
○ Percutaneous: If abscess is greater than 5 cm
○ Open: If multiloculated abscess or if percutaneous route has failed
● Repeat CT Scan 4-6 weeks after completion of antibiotics
Renal Transplant Patients
● Post-transplant UTI: Empiric broad-spectrum antibiotics
● Early UTI: within 6 months of transplant or with signs of
sepsis
○ Admit and start IV antibiotics for 14 days (may be shifted to oral)
● Late UTI: More than 6 months after transplant
○ Cystitis: 7 days
○ Pyelonephritis: 14 days
● Prophylaxis: Oral TMP-SMX 160mg/800mg BID then OD
when catheter is removed or discharge for 6 months
Candiduria
● Candida sp. In urine (regardless of count) in at least 2 specimens
taken at least 2 days apart
● Yeast cells or hyphae on microscopy with pyuria may point to
candiasis
● Treatment: Fluconazole 400mg loading dose then 200 mg OD for
7-14 days
● If resistant: IV Amphotericin B deoxycholate 0.3-1.0 mg/kg daily
● Bladder irrigation: Adjunct if refractory cystitis with azole
resistance
○ Continuous irrigation of 50mg/L Amphotericin B to sterile water for 5 days