Rosen & Barkin's 5-Minute Emergency Medicine Consult (745 page)

Urosepsis/septic shock:

• Manage airway and resuscitate as indicated
  
• IV crystalloid and vasopressors as needed
  
• Early goal-directed therapy
  

• For uncomplicated UTIs in women for most antibiotics, 3 days of therapy:
  
  • More effective than single dose
    
  • Clinically as effective as 5–10-day course with fewer side effects
    
• Resistance varies by place and changes over time:
  
  • In North America, 40–50% of
    E. coli
    are resistant to ampicillin; 3–17% to fluoroquinolones and is increasing.
    
  • Resistance to trimethoprim–sulfamethoxazole (TMP/SMX) is increasing (up to 30%).
    
  • Nitrofurantoin: In some studies, nitrofurantoin resistance is less than for other more widely used antibiotics.
    
  • Culture resistance may not correlate with clinical effect because urine antibiotic concentrations are much higher than those used in laboratory testing. However, symptom resolution may be delayed a few days in patients with resistant bacteria.
    
• Antibiotics of choice:
  
  • Nitrofurantoin
    
  • TMP/SMX
    
  • Fluoroquinolones 2nd-line treatment in women:
    
    • Sulfonamide intolerance
      
    • All quinolones equally effective (∼95% susceptibility rates) but side effects vary
      
    • High frequency of antimicrobial resistance related to recent treatment
      
    • Live in areas with unknown or >20% resistance to TMP/SMX
      
  • Oral cephalosporins may be reasonable alternatives in specific circumstances:
    
    • Require 7-day treatment regimens
      
  • Amoxicillin–clavulanate not as effective as ciprofloxacin, probably due to failure to eradicate vaginal
    E. coli
    
  • Diabetic women have increased risk of bacteriuria with Klebsiella spp.
    
  • Treat dysuria with phenazopyridine.
    
  • Treat pain with appropriate analgesics.
    
• Cranberry juice or tablets/products:
  
  • Prevents specific
    E. coli
    from adhering to uroepithelial cells but probably does not lower UTI recurrence rate in women with history of recurrent UTIs
    
  • Evidence suggests ineffective for treatment
    
• Treatment of upper tract disease—
  rule of 2s
  :
  
  • 2 L of IV crystalloid
    
  • 2 tablets of oxycodone/acetaminophen
    
  • 2 g of ceftriaxone or 2 mg/kg of gentamicin
    
  • If fever drops by 2°C and patient can retain 2 glasses of water
    
  • Discharge with fluoroquinolone for 2 wk.
    
  • Follow up in 2 days.
    

• Treat asymptomatic bacteriuria in pregnancy with 4–7-day course of antibiotics:
  
  • Nitrofurantoin:
    
    • May cause birth defects if used in 1st trimester
      
    • Contraindicated in G6PD-deficiency
      
  • Amoxicillin (not 1st-line treatment due to high rate of resistance)
    
  • Fosfomycin (safe and effective)
    
  • TMP/SMX:
    
    • SMX should be avoided late in pregnancy as kernicterus can result.
      
    • TMP should be avoided in 1st trimester (folic acid antagonist; possible birth defects).
      
  • Quinolones should be avoided:
    
    • CNS reactions
      
    • Blood dyscrasias
      
    • Effects on collagen formation
      

• Amoxicillin: 500 or 875 mg PO q12h
  
• Cefixime: 400 mg PO q24h
  
• Cefpodoxime: 400 mg PO q12h
  
• Ceftazidime: 1–2 g IV q8–12h
  
• Ceftriaxone: 1–2 g IV/IM q24h
  
• Cefuroxime: 250–500 mg PO q12h
  
• Cephalexin: 250–500 mg PO q6h
  
• Ciprofloxacin: 100–500 mg PO q12h
  
• Doripenem: 500 mg IV q8h
  
• Fosfomycin: 3 g single dose
  
• Gentamicin: 2 mg/kg IV or IM q8h
  
• Levofloxacin: 250 mg PO q24h
  
• Nitrofurantoin macrocrystals 100 mg PO q12h
  
• Norfloxacin: 400 mg PO q12
  
• Ofloxacin: 200 mg PO q12h or 400 mg IV q12h
  
• Phenazopyridine: 200 mg PO TID for 2 days:
  
  • For symptomatic treatment of dysuria
    
  • May turn urine and contact lenses orange
    
• TMP/SMX: 160 mg/800 mg PO q12h or 10 mg/kg/d IV div. q6–8–12h
  

FOLLOW-UP

• Inability to comply with oral therapy
  
• Toxic appearing, unstable vital signs
  
• Pyelonephritis:
  
  • Intractable symptoms
    
  • Extremes of age
    
  • Immunosuppression
    
  • Urinary obstruction
    
  • Consider if coexisting urolithiasis
    
  • Significant comorbid disease
    
  • Outpatient treatment failure
    
  • Late in pregnancy
    

• Well appearing, normal vital signs
  
• Can comply with oral therapy
  
• No significant comorbid disease
  
• Adequate follow-up (48–72 hr) as needed
  
• Healthy patients with uncomplicated pyelonephritis who respond to treatment in ED according to rule of 2s
  
• Pyelonephritis in early pregnancy with good follow-up may be treated as outpatients
  

Recurrent UTIs require workup for underlying pathology.

Follow-up for UTIs should start with primary care physician.

• For women who have more than 2 episodes of acute cystitis in 6 mo or 3 episodes in 1 yr, consider long-term (6–12 mo) prophylactic antibiotics or postcoital prophylaxis
  
• Pregnant women should be screened and treated for asymptomatic bacteriuria (ASB) because 20–40% of women with ASB progress to pyelonephritis.
  
• ASB in pregnant women associated with increased risk of preterm birth, low birth weight, and perinatal mortality.
  
• Treat ASB in renal transplant recipients, patients who have recently undergone a urologic procedure, and neutropenic patients.
  
• Risk factors for acute cystitis in men: Increased age, uncircumsized, HIV infection (low CD4 counts), anatomic abnormalities (BPH or urethral strictures), and sexual activity (especially insertive anal intercourse).
  
• 25% of male GU complaints are attributable to prostatitis. TMP/SMX or fluoroquinolones are 1st-line treatment.
  
• In patients with indwelling catheters, pyuria is less strongly correlated with UTI than in patients without catheters.
  

• Gupta K, Hooton TM, Naber KG, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases.
  Clin Infect Dis
  . 2011;52:e103–e120.
  
• Hooton TM. Clinical practice. Uncomplicated urinary tract infection.
  N Engl J Med
  . 2012;366(11):1028–1037.
  
• Nicolle LE, Bradley S, Colgan R, et al. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults.
  Clin Infect Dis.
  2005;40:643–654.
  
• St. John A, Boyd JC, Lowes AJ, et al. The use of urinary dipstick tests to exclude urinary tract infection.
  Am J Clin Pathol.
  2006;126:428–436.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Pyelonephritis
  
• UTI, Pediatric
  

CODES

• 590.80 Pyelonephritis, unspecified
  
• 595.9 Cystitis, unspecified
  
• 599.0 Urinary tract infection, site not specified
  

BASICS

• Bacteria colonize via retrograde contamination of rectal or perineal flora:
  
  • Infants—often hematogenous spread
    
  • Older children—vesicoureteral reflux (VUR) major risk
    
• UTI is defined by culture of a single organism of >10,000/mL on a catheterized or suprapubic specimen. Other collection techniques are not routinely used in young children for definitive diagnosis.
  
• In infants 0–3 mo old, UTI is associated with a 30% incidence of sepsis.
  
• Predisposing factors:
  
  • Poor perineal hygiene
    
  • Short urethra of female
    
  • Female > male
    
  • Infrequent voiding
    
  • Constipation
    
  • Sexual activity
    
  • Male circumcision probably reduces risk
    

• UTI found in 4–7% of febrile infants
  
• Bacterial agents:
  
  • Escherichia coli
    accounts for 80%
    
  • Klebsiella pneumoniae
    
  • Staphylococcus aureus
    
  • Enterobacter
    species
    
  • Proteus
    species
    
  • Pseudomonas aeruginosa
    
  • Enterococcus
    species