Mount Carmel Health Partners Clinical Guidelines Urinary Tract Infection

Urinary Tract Infection Clinical Guideline
Urinary Tract Infection Clinical Pathway for Females
Evaluation
Check for signs and symptoms:
• dysuria in combination with frequency and
urgency, suprapubic or low back pain
• abrupt onset of symptoms
Definition: An inflammation
of the urinary bladder,
urethra, and ureters.
Symptoms include
hematuria, pain, and
frequency.
Are there vaginal symptoms?
• gradual onset of symptoms
• vaginal discharge or bleeding
• new sexual partner or
dyspareunia
Causes: Bacterial infection,
stone, or tumor.
Treatment
Yes
UTI unlikely. Perform pelvic exam;
consider urine culture, gonorrhea,
chlamydia, wet prep microscopic
evaluation, and syphilis testing.
Consider cervicitis/vulvovaginitis,
pelvic inflammatory disease, tubal
ovarian abscess
No
Obtain urine specimen
• clean catch urine: squamous epithelial cells suggest contamination
• consider urine pregnancy testing of female of appropriate age
• catheterized patients: replace catheter and collect urine from clean catheter
• urine dipstick: sensitivity and specificity is comparable to microscopic analysis
• microscopic urinalysis: if sterile pyuria (no bactiuria) is present, consider appendicitis, enteritis, perinephritic abscess, diverticulitis, renal papillar
necrosis, renal tuberculosis, fungal infection, polycystic kidney disease, renal sarcoidosis, lymphoma, or leukemia
• urine culture: positive culture is >100,000 colony forming units;
For most menopausal
women, consider
urethral trauma from
sexual intercourse;
consider atrophic
vaginitis, dryness,
vaginal inflammation;
consider irritant from
scented soaps, sprays,
creams, or other
hygiene products;
consider urethral
stricture
Are there urinary findings of infection?
• presence of blood, leukocyte esterase or
protein is very sensitive of infection
• presence of nitrates is very specific of
infection; refer to predictive value
table and likelihood ratio table
(see Tables Three and Four)
No
Yes
Lower UTI
(cystitis)
No
Are there additional signs and symptoms
present to suggest an upper urinary tract
infection?
• fever of 38.5° C or 101.3° F and/or
chills; consider antibiotic use prior to
further evaluation
• flank pain or costovertebral tenderness
• nausea or vomiting
• abdominal or pelvic pain
Uncomplicated UTI Tx
Uncomplicated UTI Tx
Refer to Table Two:
Antimicrobial Agents
for the Management of
Acute Uncomplicated
Cystitis in Women
Complicated UTI Tx
• Same as uncomplicated,
except treat for 7-14 days
• Nitrofurantoin is the
first-line agent for pregnant
patients with cystitis
• Trimethoprim sulfamethoxazole,
1 DS (double strength) orally
every 12 hours for 10-14 days; if
pregnant, avoid in first and third
trimesters OR
• Ciprofloxacin, 500 mg orally
every 24 hours for 7-14 days OR
• Augmentin, 875 mg orally every
12 hours for 7-14 days
Yes
Upper UTI (pyelonephritis)
• consider WBC evaluation and
blood cultures with sensitivity
if a systemic illness is
suspected
• send urine for culture and
sensitivity
Complicated UTI Tx
• If GFR <60 ml/min.,
ceftriaxone 1 gm IV every
24 hours OR
• If GFR ≥60 ml/min.,
gentamicin 5-7 mg/Kg IV
every 24 hours AND
ampicillin 1 gm every 6-12
hours OR ertapenem 1 gm
IV for 14 days
July 2017