Urinary Tract Infection (UTI)
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Urinary tract infections may involve the upper or lower urinary tract. Infections may be complicated or uncomplicated. Uncomplicated cystitis is a lower UTI in a non-pregnant woman of reproductive age and who has a normal urinary tract. All other UTIs should be regarded as complicated. The commonest causative pathogens for UTIs irrespective of the group of patients involved in Tanzania are Escherichia coli, Klebsiella pneumonia, Proteus spp. and Staphlococcus aureus.
Note:
- Differentiation of upper from lower urinary tract infection in young children is not possible on clinical grounds
- Upper UTI is a more serious condition and requires longer and sometimes intravenous antimicrobial treatment
- Special considerations should be given in the following groups of patients: children, pregnant women, elderly (>60 years) and other individuals with functional or structural abnormalities in the urinary tract.
Clinical presentations of lower UTI (cystitis)
- Suprapubic pain/tenderness, dysuria, frequency, and urgency
- Pyuria and occasionally haematuria
- Temperature 38°C or higher
Clinical presentations of upper UTI (pyelonephritis)
- Flank pain/tenderness
- Pyuria and occasionally haematuria
- Temperature 38°C or higher
- Vomiting
Clinical presentations of catheter associated UTI (CAUTI)
- Presence of symptoms and signs of UTIs (as stated in cystitis or pyelonephritis above) occurring in a person whose urinary tract is currently catheterized or has had a catheter in place within the past 48 hours.
Clinical presentations of urosepsis
- Any of the above features of cystitis or pyelonephritis plus two or more of the following: (1) Temperature >38° C or <36° C; (2) tachycardia >90 beats per minute; (3) tachypnoea >20/minute, (3) WBC count>12,000/mm3 or <4000/mm3; confusion, hypotension or any other evidence of organ dysfunction as a sequelae of UTI complications
Investigations
- Quantitative or semi-quantitative urinalysis (high protein, low sugar, nitrites positive, leucocyte esterase positive, and low pH) and urine microscopy (>8–10 WBC/HPF) may be suggestive of UTIs
- Quantitative urine culture (growth of at least 104 or 105 colony forming units of bacteria/ml of urine) and antimicrobial sensitivity testing. Concomitant urine and blood cultures are indicated in case of urosepsis
- Urinary LAMM – in patients with suspected to have genitourinary TB
- Ultrasound (kidney and pelvis) to exclude stones or structural abnormalities in patients with recurrent UTI
Note: Positive WBC counts on urinalysis or urine microscopy + compatible 2 or more clinical presentations supported by urine culture in centers where this test is available.
Non-pharmacological Treatment
- Ensure adequate hydration
- Voiding of urine whenever an urge to micturate occurs; or after sexual intercourse in adults.
- Removal of indwelling bladder catheter (where indicated)
Pharmacological Treatment
Analgesics in severe dysuria and flank pain
Adult:
A: paracetamol (PO) 500-100mg every 6-8hours.
Children:
A: paracetamol (PO) 15 mg/kg/dose 4–6hourly when required to a maximum of 4 doses per 24hours;
Uncomplicated cystitis
Adults:
A: nitrofurantoin (PO) 100mg 12hourly for 5days
OR
B: flucloxacillin + amoxicillin (FDC) (PO) 500mg 8hourly for 5days
Complicated cystitis
Adults:
A: ciprofloxacin (PO) 500mg 12hourly for 7days
OR
B: amoxicillin+ clavulanic acid (FDC) (PO) 625mg 12hourly for 7days
For pregnant women and adolescents
A: nitrofurantoin (PO) 100mg 12hourly for 5days
OR
B: amoxicillin + clavulanic acid (FDC) (PO) 625mg 12hourly for 7days
For children
A: nitrofurantoin (PO) 50mg 12hourly for 5days (Do not give nitrofurantoin if the child has G6PG deficiency or porphyria)
OR
B: amoxicillin + clavulanic acid (FDC) (PO) 40mg/kg/day of amoxicillin in 3divided doses (maximum 2000 mg amoxicillin) for 7days
Acute Pyelonephritis
Outpatient therapy is only indicated for women of reproductive age, who do not have any of the danger signs – see referral criteria. All other patients should be referred.
A: ciprofloxacin (PO) 500mg 12hourly for 10days
OR
B: ceftriaxone (IV) 1g [For a child ceftriaxone (80 mg/kg I.V or I.M)] 24hourly for 5days
Catheter associated UTI (CAUTI)
Patients with indwelling or suprapubic catheters and nephrostomy tubes invariably become carriers of potential bacterial pathogens and routine antimicrobial treatment is not indicated. However, judicious evidence from clinical and laboratory evidence is critical to warranty antimicrobial therapies.
A: ciprofloxacin (PO) 500mg 12hourly for 7days
Urosepsis
A: gentamicin (I.V/I.M) 120mg [For children 7.5mg/kg] 24hourly for 5days (completion of 10days treatment to be guided by culture results)
AND
D: ceftriaxone + sulbactam (FDC) (IV) 1g [For children 80 mg/kg I.V or I.M] 24hourly for 5days
Alternatively;
A: gentamicin (I.V/I.M) 120mg [For children 7.5mg/kg] 24hourly for 5days (completion of 10 days’ treatment to be guided by culture results)
AND
S: piperacillin + tazobactam (FDC)(IV) 4.5g 6-8hourly for 5–7days
OR
S: Meropenem (IV) 250–500mg 8hourly for 5–7days
Once results for urine and blood cultures are available change the antibiotic treatment options accordingly.
Referral
Refer the patient urgently to the next facility with adequate expertise and facilities if:
Acute pyelonephritis with:
- Vomiting
- Features of suggestive of urosepsis
- Diabetes mellitus
Acute pyelonephritis in:
- Pregnant women
- Women beyond reproductive age
- Men