Urinary Tract Infections

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Asymptomatic bacteriuria

Asymptomatic bacteriuria (ASB) is the presence of 100,000 microorganisms per milliliter of urine without clinical symptoms.5 Usually no treatment is needed. Screening for ASB is not recommended for nonpregnant women,6 elderly living in the community,7 diabetic women,8 institutionalized elderly,9 or persons with spinal cord injuries.9 However, screening with treatment of positive cultures is recommended for pregnant women in the first trimester.5, 6, 7

Uncomplicated UTIs

An uncomplicated UTI is diagnosed in patients with cystitis symptoms who have normal urinary tract anatomy, no fever, no kidney disease, and no contributing medical problems such as diabetes, neurogenic bladder, or renal stones.5, 10, 11 Characteristic symptoms of cystitis include dysuria, urgency, increased frequency, pyuria, and bacteriuria on urinalysis, and sometimes suprapubic pain, fullness, and hematuria.5, 6 No long-term adverse effects have been seen on renal function or increased

Acute pyelonephritis

Acute pyelonephritis is an infection of the kidney that starts either from ASB or from an ascending bladder infection.6 Pyelonephritis can develop from an uncomplicated UTI; however, it is more commonly seen in the setting of obstruction, urinary tract malformations, urolithiasis, or pregnancy.6 Typical symptoms include flank pain, chills, fever (>38°C), nausea or vomiting, and costovertebral angle tenderness. Common symptoms of cystitis also can be present, especially dysuria, increased

Recurrent UTI

Recurrent UTI is defined as at least three episodes of symptomatic uncomplicated UTI with one or more documented positive cultures in 12 months,6, 12 without complicating factors. A relapse is infection with the same organism as the previous UTI.5 A reinfection is when the initial UTI is treated, the patient becomes asymptomatic with a negative culture in between, and then develops symptoms again, or when the second infection is caused by a second organism.5, 6 American College of Obstetricians

Men

Only 20% of UTIs occur in men. Male UTI rates increase dramatically with age, and most are complicated by prostate pathology.1 Men at low risk with a first UTI may be treated using a 3-day course with a first-line agent.14 Low-risk men are defined as under age of 45, with no prostatitis, urethritis, obstructive symptoms, or hematuria.14 Urological evaluation is recommended in adolescents, men with febrile UTI, pyelonephritis, recurrent infections, or when complicating factors are suspected.9

Nosocomial UTIs

There has been a recent interest in prevention of catheter-associated UTI (CAUTI) in the hospital setting, since the Centers for Medicare and Medicaid Services (CMS) identified this as one of six unacceptable diagnoses for payment if UTI was not present on admission.24, 25 As of 2009, a CAUTI is one that occurs in a patient who had an indwelling urethral catheter at the time of or within 48 hours of the event.26 A previous definition included those with a catheter within 7 days of the event.16

Pediatric patients

Infants and children diagnosed with UTIs more often present to emergency rooms than outpatient clinics.48 In any setting, prompt identification, treatment, and follow-up of pediatric UTIs are key to preventing long-term complications.

When considering whether a UTI is the cause of unexplained fever in infants or children, physicians should assess pretest probability, using prevalence data by age, gender, race, and for male patients, circumcision status. A meta-analysis by Shaikh and colleagues49

Immunosuppressed patients

There is sparse literature on UTIs in immunosuppressed hosts, perhaps because opportunistic infections are more likely to manifest in other organ systems.71 Viruses such as BK virus, adenovirus, and cytomegalovirus are a relatively commonly cause of UTIs, particularly hemorrhagic cystitis, in the immunocompromised.72 UTIs are common in renal transplant patients, particularly in the first 3 months after transplantation.73 An international guideline includes the following recommendations for

Patients with spinal cord injury

Urologic complications are a primary source of morbidity and until recently were the leading cause of death for the estimated 260,000 Americans living with spinal cord injury (SCI).75 Factors leading to UTIs in SCI patients are impaired voiding, stone formation secondary to acute bone loss, and altered sensation and symptoms. Variables linked to development of UTI in spinal cord injured patients are prior history of UTI, higher degree of functional impairment, and lack of exercise.76Table 1

Seniors

UTIs occur frequently in the elderly, and contribute significantly to morbidity and mortality. UTIs are a principal cause of falls in nursing home patients,91 especially those with dementia.92 UTIs frequently complicate acute medical conditions such as stroke.93 A clear association exists between UTI and acute coronary syndrome, suggesting that systemic inflammation may even precipitate coronary ischemia.94

Several factors make the diagnosis of UTIs in the elderly challenging. ASB is highly

Diabetic patients

ASB is common in diabetic patients. Although diabetics with ASB have higher rates of developing symptomatic UTIs, there is no good evidence that antibiotic treatment of ASB reduces UTI rates, as recolonization occurs rapidly.103 Nicolle states succinctly: “Bacteriuria is benign, and seldom permanently eradicable.”104 The United States Preventive Services Task Force does not recommend screening for ASB in diabetic patients.8

However, a UTI in a diabetic patient is considered a complicated UTI.

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References (105)

  • N.E. Tolkoff-Rubin et al.

    Urinary tract infection in the immunocompromised host. Lessons from kidney transplantation and the AIDS epidemic

    Infect Dis Clin North Am

    (1997)
  • D.D. Cardenas et al.

    Hydrophilic catheters versus noncoated catheters for reducing the incidence of urinary tract infections: a randomized controlled trial

    Arch Phys Med Rehabil

    (2009)
  • D.J. De Ridder et al.

    Intermittent catheterisation with hydrophilic-coated catheters (SpeediCath) reduces the risk of clinical urinary tract infection in spinal cord injured patients: a prospective randomised parallel comparative trial

    Eur Urol

    (2005)
  • R.O. Darouiche et al.

    Impact of StatLock securing device on symptomatic catheter-related urinary tract infection: a prospective, randomized, multicenter clinical trial

    Am J Infect Control

    (2006)
  • S. Eriksson et al.

    Circumstances surrounding falls in patients with dementia in a psychogeriatric ward

    Arch Gerontol Geriatr

    (2009)
  • J.B. Sims et al.

    Urinary tract infection in patients with acute coronary syndrome: a potential systemic inflammatory connection

    Am Heart J

    (2005)
  • R.R. Gokula et al.

    Inappropriate use of urinary catheters in elderly patients at a midwestern community teaching hospital

    Am J Infect Control

    (2004)
  • E. Hing et al.

    National health statistics reports. National hospital ambulatory medical care survey: 2006 outpatient department summary

    (2008)
  • S.M. Schappert et al.

    National health statistics reports. Ambulatory medical care utilization estimates for 2006. Summary

    (2006)
  • American College of Obstetricians and Gynecologists

    ACOG Practice Bulletin No. 91: treatment of urinary tract infections in nonpregnant women

    Obstet Gynecol

    (2008)
  • J.S. Sheffield et al.

    Urinary tract infection in women

    Obstet Gynecol

    (2005)
  • J. Car

    Urinary tract infections in women: diagnosis and management in primary care

    BMJ

    (2006)
  • N. Calogne

    Screening for asymptomatic bacteriuria in adults: U.S. Preventive Services Task Force reaffirmation recommendation statement

    Ann Intern Med

    (2008)
  • M. Grabe

    Uncomplicated urinary tract infections in adults

  • F.M. Wagenlehner et al.

    An update on uncomplicated urinary tract infections in women

    Curr Opin Urol

    (2009)
  • L. De Alleaume et al.

    Clinical inquiries. When are empiric antibiotics appropriate for urinary tract infection symptoms?

    J Fam Pract

    (2006)
  • M. Gopal et al.

    Clinical symptoms predictive of recurrent urinary tract infections

    Am J Obstet Gynecol

    (2007)
  • D. Richards et al.

    Response to antibiotics of women with symptoms of urinary tract infection but negative dipstick urine test results: double blind randomised controlled trial

    BMJ

    (2005)
  • D.P. Breen et al.

    Clinical inquiries. What is the recommended workup for a man with a first UTI?

    J Fam Pract

    (2007)
  • H.D. Patel et al.

    Can urine dipstick testing for urinary tract infection at point of care reduce laboratory workload?

    J Clin Pathol

    (2005)
  • D.R. Guay

    Contemporary management of uncomplicated urinary tract infections

    Drugs

    (2008)
  • D.R. Guay

    Cranberry and urinary tract infections

    Drugs

    (2009)
  • R.G. Jepson et al.

    Cranberries for preventing urinary tract infections

    Cochrane Database Syst Rev

    (2008)
  • M.E. Falagas et al.

    Probiotics for prevention of recurrent urinary tract infections in women: a review of the evidence from microbiological and clinical studies

    Drugs

    (2006)
  • B.B. Lee et al.

    Methenamine hippurate for preventing urinary tract infections

    Cochrane Database Syst Rev

    (2007)
  • C. Perrotta et al.

    Oestrogens for preventing recurrent urinary tract infection in postmenopausal women

    Cochrane Database Syst Rev

    (2008)
  • C. Zhan et al.

    Identification of hospital-acquired catheter-associated urinary tract infections from Medicare claims: sensitivity and positive predictive value

    Med Care

    (2009)
  • National Healthcare Safety Network (NHSN)

    Catheter-Associated Urinary Tract Infection (CAUTI) Event

  • A.M. Nasr et al.

    Evaluation of the use vs nonuse of urinary catheterization during cesarean delivery: a prospective, multicenter, randomized controlled trial

    J Perinatol

    (2009)
  • C.C. Liang et al.

    Postoperative urinary outcomes in catheterized and noncatheterized patients undergoing laparoscopic-assisted vaginal hysterectomy—a randomized controlled trial

    Int Urogynecol J

    (2009)
  • L. Sekhavat et al.

    The effect of early removal of indwelling urinary catheter on postoperative urinary complications in anterior colporrhaphy surgery

    Aust N Z J Obstet Gynaecol

    (2008)
  • B.W. Trautner et al.

    Prevention of catheter-associated urinary tract infection

    Curr Opin Infect Dis

    (2005)
  • C. Simpson et al.

    Nosocomial UTI: are we treating the catheter or the patient?

    Clin Nurse Spec

    (2005)
  • D.J. Stickler

    Bacterial biofilms in patients with indwelling urinary catheters

    Nat Clin Pract Urol

    (2008)
  • M. Grabe et al.

    Catheter-associated UTIs

  • Y. Igawa et al.

    Catheterization: possible complications and their prevention and treatment

    Int J Urol

    (2008)
  • J. Topal et al.

    Prevention of nosocomial catheter-associated urinary tract infections through computerized feedback to physicians and a nurse-directed protocol

    Am J Med Qual

    (2005)
  • D. Parker et al.

    Catheter-associated urinary tract infections: fact sheet

    J Wound Ostomy Continence Nurs

    (2009)
  • H. Godfrey et al.

    Preventing and managing catheter-associated urinary tract infections

    Br J Community Nurs

    (2005)
  • K. Schumm et al.

    Types of urethral catheters for management of short-term voiding problems in hospitalized adults: a short version Cochrane review

    Neurourol Urodyn

    (2008)
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