Urinary Tract Infection

Page updated Winter 2021.
DisclaimerMedicine is an ever-changing science.  We have been witnessing changes in diagnostic and therapeutic modalities and guidelines during last several years. We have used sources believe to be reliable for purpose of this website including AUA guidelines, EAU guidelines, NCCN guidelines, Campbell-Walsh-Wein Urology, UpToDate, Merck Manual, Lexi-Comp, FDA website, and other reputable resources. However, due to possibility of human error or changes in medicine, readers are required to confirm the information provided in this website with other sources. Readers are specially required to read all parts of the product information sheet included in the package of each drug they plan to administer and follow those instructions. Readers are also needed to follow instructions of FDA and other regulatory bodies and their own department in this regard. Authors can cite information provided in our textbooks or they need to cite the original resources. This website serves as a general framework. We and other users would adjust the approach per departments policies and patients situation. Forms can be used by other health care professionals.

Acute Uncomplicated Cystitis

Nitrofurantoin monohydrate

100 mg twice daily for 5 days

It is an appropriate choice.

Its efficacy is comparable to 3 days of trimethoprim-sulfamethoxazole.

There is minimal resistance and propensity for collateral damage. 

Trimethoprim-sulfamethoxazole 

160/800 mg twice-daily for 3 days.
 
It is an appropriate choice.

Fluoroquinolones

3-day regimens

Options: ofloxacin, ciprofloxacin, and levofloxacin
 
Highly efficacious

Should be considered an alternative antimicrobials for acute cystitis, when other options don't work. 

Fosfomycin

3 g in a single dose

It has inferior efficacy. 

B-Lactam agents

3–7-day. Choices are: 
amoxicillin-clavulanate, cefdinir, cefaclor, and cefpodoxime-proxetil

Inferior efficacy

More adverse effects

Should be used with caution for uncomplicated cystitis.

Emphysematous Cystitis

Antibiotics: 

Broad gram-negative coverage- IV

Enterococcal coverage iGram stain shows gram-positive cocci

Bladder drainage

Treatment of comorbid conditions like diabetes

Surgery:

Rarely needed. Case reports have described debridement, partial cystectomy, and total cystectomy.


Asymptomatic Bacteriuria 

Do not screen or treat:


Pediatric patients


Women without risk factors


Post-menopausal women


Patients with well-regulated diabetes mellitus


Elderly institutionalised patients


Patients with dysfunctional and/or reconstructed lower urinary tracts


Patients with renal transplants


Prior to arthoplasty surgeries


Patients with recurrent urinary tract infections


Pyuria accompanying asymptomatic bacteriuria: 


Should not be treated with antimicrobial therapy.


Screen and treat 


Prior to urological procedures breaching the mucosa


Pregnant women


Renal transplant patients


If >1 month after renal transplant:  no treatment.


Nonrenal solid organ transplant: no treatment.


High-risk neutropenia (absolute neutrophil count <100 cells/mm3, ≥7 days duration following chemotherapy):

No recommendation for or against treatment

Asymptomatic Bacteriuria and Cystitis in Pregnancy


Cephalexin

500 mg four times daily

Nitrofurantoin

100 mg four times daily

No G6PD deficiency




Acute Pyelonephritis- Not Requiring Hospitalization

Oral ciprofloxacin 

500 mg twice daily for 7 days

Intravenous ciprofloxacin

400-mg, one initial dose

May or may not be given.

Acute Pyelonephritis- Requiring Hospitalization

Intravenous Antibiotics for 10-14 days. Choices are:

Fluoroquinolone- Not a good choice for complicated PN.

Extended-spectrum cephalosporin

Extended-spectrum penicillin 

Carbapenem

In case of gram-positive cocci in initial Gram stain enterococcal coverage should be included.

Urosepsis

Diagnosis:

Urine culture

Two sets of blood culture

Other related tests to rule out other sources of sepsis

Treatment

Resuscitation

Antibiotics- IV broad spectrum antimicrobials. Refer to common medication page.

Removal of foreign bodies

Decompression of obstruction 

Drainage of abscesses

Acute Pyelonephritis in Pregnancy

Hospitalize 

IV fluids

Cooling blanket

Acetaminophen

IV antibiotics:

Second or third generation cephalosporins

Carbapenems: in severe multidrug-resistant infection.

Renal ultrasound: if no improvement in 72 hours

Asymptomatic Candiduria

Elimination of predisposing factors

Indwelling bladder catheters 

Systemic antifungal treatment 

Treatment with antifungal agents is NOT recommended.

Treat only if:

Neutropenic- Candidemia Protocol

Very low-birth-weight infants (<1500 g)- Candidemia Protocol

Before urologic manipulation-  Fluconazole

For doses refer to common medication page.


Symptomatic Candida Cystitis

Antifungal treatment

Refer to common medication page.

Amphotericin B deoxycholate Irrigation:

50 mg/L sterile water daily for 5 days.

Irrigation may be helpful for treatment of cystitis due to fluconazole-resistant species, such as C. glabrata and C. krusei.

Symptomatic Ascending Candida Pyelonephritis

Antifungal treatment

Refer to common medication page.

Elimination of urinary tract obstruction

Nephrostomy tubes or stents removal or replacement


Fungus Balls

Surgical intervention

Antifungal treatment

Amphotericin B deoxycholate Irrigation:

Use nephrostomy tubes, if present.

25–50 mg in 200–500 mL sterile water




Infected Hydronephrosis and Pyonephrosis

Antimicrobial Therapy

Drainage- ureteral catheter or percutaneous nephrostomy tube 


Emphysematous pyelonephritis

Fluid resuscitation

Glucose management

Electrolyte management

Antimicrobial therapy 

Drainage:

Ureteral catheter or percutaneous nephrostomy tube 

Nephrectomy:

Only if there is extensive diffuse gas with renal destruction.


Renal Abscess

<3 - 5 cm

Antibiotics alone

Drainage if not responsive to initial antibiotic therapy.

Drainage if immunocompromised.

> 5 cm

Antibiotics

Percutaneous drainage

They usually require multiple drains, and multiple drain manipulations. 

Surgical washout and potential nephrectomy might be needed.


Perinephric Abscess

<3 cm

Antibiotics:

There should be gram negative and staphylococcal coverage. 

Percutaneous drainage

Inot responsive to initial antibiotic therapy.

> 3 cm

Antibiotics

Percutaneous drainage

Addressing the underlying problem


Xanthogranulomatous Pyelonephritis

Antibiotics

Nephrectomy:

It is usually performed.

Partial nephrectomy:

If localized.

Malacoplakia

Antibiotics 

Recurrent infection should be controlled.


Tuberculosis

Most common presentations:

Hematuria (gross or microscopic), sterile pyuria, storage symptoms, dysuria, fever, and weakness.

Other presentations: 

Pyospermia and hematospermia may occur in men with prostate tuberculosis in endemic areas. If there is history of tuberculosis, investigate for urogenital tuberculosis.

Tuberculous epididymitis may occur, typically as chronic epididymitis, in high-risk groups such as men with immunodeficiency and those from endemic areas. It frequently results in a discharging scrotal sinus.


Diagnosis:

Three sequential early morning urine samples:

Cultured for acid-fast bacilli (AFB)

and

NAAT for M. tuberculosis 

AFB culture and NAAT test of  other secretions

Prostate secretion

Ejaculate

Draining scrotal fistula

Fine needle aspiration and biopsy