UTI / PYELONEPHRITIS

 

Etiology:

  • E. Coli ( clue is pH <5.5) or Proteus, Klebsiella (clue is pH >7.5) or Chlamydia, Ureaplasma urealyticum (cause of AUS. WBC with few or no bacteria) or Staph. saprophyiticus.
  • Anatomical defect
  • BPH
  • Sexual activity
  • Cathaterization
  • Female sex
  • DM
  • Pregnancy
  • Chemical irritants (douches, spermicides)

S  &  S :

  1. Dysuria, frequency, urgency in "lower UTI" and AUS.
     
  2. Asymptomatic in Elderly (treatment generally not indicated) and Pregnant woman (treatment   is indicated).
     
  3. Dysuria, frequency, urgency, CVA tenderness, +/- fever/chills in Pyelonephritis.
     
  4. Dysuria, frequency, urgency and (+)ve discharge on pelvic exam unless it is cystitis.

DX:

  1. Dipstick analysis for Leukocyte esterase (indicates presence of WBC = pyuria) and for Nitrates (screens for G (-)ve bacteria) is a reliable test.
     
  2. "Lower UTI": 2 - 5 WBC/HPF, any Bacteria on unspun (or 15/HPF on spun) urine specimen, Hem positive, (+)ve Gram stain. Bacteriuria may not be detected microscopically with infection of 102 - 104 CFU/ml.
     
  3. Pyelonephritis: bacteriuria / pyuria (more than in lower UTI) and sometimes leukocyte casts.
     
  4. Urine culture is the definitive diagnostic tool with >1000/ml colony count.
     
  5. Acute prostatitis - fever, severe dysuria, difficulty/inability to urinate, prostate pain. Prostate is boggy. Do not apply pressure and do not massage. Do not place Foley - this may  precipitate bacterimia. Place suprapubic catheter if pt is in retention.

Treatment:

  1. 1.    Lower UTI
     
      1. TMP/SMX (Bactrim) DS x BID for 1 day or 3 days or Cipro 250 - 500mg BID x 3 days
      2. If  contraindication to TMP/SMX, AM/CL 875mg BID is an alternative and used for  3 days or 7 - 10 days  in pregnant female, diabetic pt.
      3. Young pts with frequent UTI who are sexually active may benefit from post-coitus PO antbx 1 dose, either TMP/SMX or Cipro.
         
  2. Pyelonephritis
      1. If  young and  no underlying diseases  pt is given in the ER  IVF x 2L, Amp +    Sulbactam (Unasyn) IV and DC home with Cipro x 10-14 days or AM/CL x 10-14 days.  Doing CBC to guide your disposition is not considered a standard of care.
         
      2. If pregnant or diabetic, admit for IV antbx.

 

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