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