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