CLINICAL MANAGEMENT GUIDELINE

Lower urinary tract infectious disease

ICD10: Urinary tract infection, site not specified [N39.0]

Treatment: Empirical treatment for non-critical lower UTI

Definition:

Acute bacterial, viral or fungal infection of the urinary tract. E.coli is the most common organism in females' UTI, and staphylococcus saprophyticus is the second most common causative organism.

Pathophysiology:

In females, ascending infection from the vagina through the urethra is the most common. Urinary incontinence increases the risk.

Manifestations:

  1. Cystitis: dysuria, urinary frequency, urinary urgency, suprapubic pain, nocturia, pus-urine, and may associated with hematuria (rare).

  2. Genital pruritus or discharge.

Investigations:

  1. Urinalysis: microscopically (WBC casts) + cytometry of > 10 WBC/mm^3.

  2. Dipstick: +ve for leukocyte esterase and nitrite (+ve in Enterobacteriaceae).

In the case of catheter in-place, take the sample from the catheter.

  1. Gram stain. (BEFORE: giving any antibiotics to avoid false negatives.)

  2. Urine culture; mid-stream clean catch; > 100 CFU/mL symptomatic UTI and >100000 CFU/mL for asymptomatic UTI.

  3. Pelvic CT for upper UTI.

    • US or IV Urogram.

Risk factors:

  1. Females have a lifetime risk of 50%-60%.

  2. Active sexual life & history of recurrent UTI (multi-partners, think chlamydia or gonorrhea) .

  3. Using spermicides, even in condoms.

  4. post-menopausal; risk of recurrent UTI, due to vaginal atrophy, incontinence.

  5. Iatrogenic; Foreign body or drug induce UTI.

  6. Immunocompromising co-morbidities; uncontrolled DM II, SCA.

  7. pregnancy; asymptomatic UTI (common), w/ high risk of pyelonephritis.

DDx: 1. Interstitial etiology.

  • Malignancy.
  • non-infectious.
  • painful bladder syndrome.
  • Urethral diverticulum.
  • Radiation-induced.

PMID: 31105774, 11237808, 15136308, EAU Guidelines, 15629728, 12020306, 9098661, 1580271,


Targeted organisms:

  1. Gram -ve: Escherichia coli (most common in females, and <50% in men), other Enterobacteriaceae; Klebsiella pneumonia, and Proteus mirabilis, Providencia Pseudomonas aeruginosa (common in Catheter-related UTI), and Acinetobacter.
  1. Gram +ve: Staphylococcus saprophyticus, Enterococci

Your choice of empirical antibiotics depends on your clinical judgment of causative organisms, local history of bacterial resistance, organs involvements, adverse effect profile, and cost/insurance coverage.

NOTE: Treating physicians should have high sensitivity toward sepsis risk, especially, if patient start to vitally deteriorate.

Managment: Navigate between the lines of management based on isolate bacteria, patient's contraindications, history of local bacterial resistance, renal functions, AE tolerance, and cost/insurance coverage.

1st line:

Option 1: Nitrofurantoin: 100 Mg, PO, BID X 4-7 days.

AE: Headach, Nausea. It has poor tissue penetraton; not recommended if prostatits was associated.

Option 2: trimethoprim-sulfamethoxazole: 160/800 mg, PO, BID X 3 days.

It has poor tissue penetraton; not recommended if prostatits was associated. Not recommended if E.coli has a history of resistance in your local community.

Option 3: fosfomycin: 3 g mixed in water, OD, STAT.

AE: Headache, Diarrhea.

Option 4: pivmecillinam: 400 mg, PO, BID X 5 days.

AE: Diarrhea, nausea

2nd line:

Option 5: Beta- lactamase: 1. Amoxicillin/clavunate 500 mg, PO, BID, 5-7 days. 2. Cefadroxil 500 mg, PO, BID, 5-7 days.

3ed line:

Option 6: Floruquines: 1. Ciprofloxacin 250 or 500 mg, PO, BID, 3 days. 2. Levofluxacin 250 mg, PO, BID, 3 days.

Reserve for sever infection profile. AE: Neuromuscular & skeletal: Musculoskeletal.

PMID: 21292654, 22318279, AUA/CUA/SUFU Guideline (2019)

Treatments

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