Complicated Urinary Tract Infections

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Continuing Education Activity

Urinary tract infections (UTIs) are among the most common presenting causes of sepsis in hospitals. Some are simple UTIs that can be managed with outpatient antibiotics and lead to almost universally good outcomes. However, complicated urinary tract infections may lead to florid urosepsis, which can be fatal. Several risk factors can complicate urinary tract infections and lead to treatment failure, repeat infections, or significant morbidity and mortality. It is vitally important to determine if the patient's infection may have resulted from one of these risk factors and whether the episode is likely to resolve with first-line antibiotics. Complicated urinary tract infections are those that present with greater morbidity, carry a higher risk of treatment failure, and typically require longer antibiotic courses, frequently requiring additional workup. Complicated urinary tract infections include those that occur: in males, in pregnant females (including asymptomatic bacteriuria), as a result of obstruction, hydronephrosis, renal tract calculi, or colovesical fistula, in immunocompromised patients or the elderly, due to atypical organisms, after instrumentation, involve urinary catheters, in renal transplant patients, in patients with impaired renal function, after prostatectomies or radiotherapy. Additionally, urinary tract infections that recur despite adequate treatment are considered complicated. This activity reviews the evaluation and management of complicated urinary tract infections and highlights the role of interprofessional team members in collaborating to provide well-coordinated care and enhance outcomes for affected patients.

Objectives:

  • Describe the criteria for complicated urinary tract infections.
  • Outline populations in whom all urinary tract infections are complicated.
  • Summarize management considerations for patients with complicated urinary tract infections.
  • Explain the importance of improving coordination amongst the interprofessional team to enhance care for patients affected by complicated urinary tract infections.

Introduction

Urinary tract infections (UTIs) are among the most common causes of sepsis presenting to hospitals. UTIs have a wide variety of presentations. Some are simple UTIs that can be managed with outpatient antibiotics and carry a reassuring clinical course with almost universal good progress. On the other end of the spectrum, florid urosepsis in a comorbid patient can be fatal. UTIs can also be complicated by several risk factors that can lead to treatment failure, repeat infections, or significant morbidity and mortality with a poor outcome. It is vitally important to determine if the presenting episode results from these risk factors and whether the episode is likely to resolve with first-line antibiotics.[1][2][3][4]

It is important to properly define a complicated UTI as an infection that carries a higher risk of treatment failure. These typically require longer courses of treatment, different antibiotics, and sometimes additional workup.

In a clinical context that is not associated with treatment failure or poor outcomes, a simple UTI (or simple cystitis) is an infection of the urinary tract due to appropriate susceptible bacteria. Typically this is an infection in an afebrile non-pregnant immune-competent female patient. Pyuria and/or bacteriuria without any symptoms is not a UTI and may not require treatment. An example would be a patient with a Foley catheter or an incidental positive urine culture in an asymptomatic, afebrile non-pregnant immune-competent female. A complicated UTI is any urinary tract infection other than a simple UTI as defined above. Therefore, all urinary tract infections in immunocompromised patients, males, and those associated with fevers, stones, sepsis, urinary obstruction, catheters, or involving the kidneys are considered complicated infections.

The normal female urinary tract has a comparatively short urethra and, therefore, carries an inherent predisposition to proximal seeding of bacteria. This anatomy increases the frequency of infections. Simple cystitis, a one-off episode of ascending pyelonephritis, and occasionally even recurrent cystitis in the proper context can be considered a simple UTI, provided there is a prompt response to first-line antibiotics without any long-term sequela.

Any urinary tract infection that does not conform to the above description or clinical trajectory is considered a complicated UTI. In these scenarios, one can almost always find protective factors that failed to prevent infection or risk factors that lead to poor resolution of sepsis, higher morbidity, treatment failures, and reinfection.[5][6][7] The reason for the distinction is that complicated UTIs have a broader spectrum of bacteria as an etiology and have a significantly higher risk of clinical complications.[8] The presence of urinary tract stones and catheters is likely to increase the incidence of recurrences compared to patients without these foci of bacterial colonization.[9]

Examples of a complicated UTI include:

  • Infections occurring despite the presence of anatomical protective measures (UTIs in males are by definition considered complicated UTIs)
  • Infections occurring due to anatomical abnormalities, for example, an obstruction, hydronephrosis, renal tract calculi, or colovesical fistula
  • Infections occurring due to an immune-compromised state, for example, steroid use, post-chemotherapy, diabetes, elderly population, HIV)
  • Atypical organisms causing UTI
  • Recurrent infections despite adequate treatment (multi-drug resistant organisms)
  • Infections are occurring in pregnancy (including asymptomatic bacteriuria)
  • Infections that occur after instrumentation, such as placing or replacement of nephrostomy tubes, ureteric stents, suprapubic tubes, or Foley catheters
  • Infections in renal transplant and spinal cord injury patients
  • Infections in patients with impaired renal function, dialysis, or anuria
  • Infections following surgical prostatectomies or radiotherapy

Etiology

Most urinary tract infections are due to the colonization of the urogenital tract with rectal and perineal flora. The most common organisms include Escherichia coli, Enterococcus, Klebsiella, Pseudomonas, and other Enterococcus or Staphylococcus species. Of these, Escherichia coli is the most common, followed by Klebsiella. Residential care patients, diabetics, and those with indwelling catheters or any form of immunocompromise can also colonize with Candida.[10] E. coli and possibly Klebsiella overwhelmingly cause simple UTIs. Complicated UTIs tend to be caused by a much wider range of organisms which is significant because multidrug resistance is increasing, and therefore specific antibiotic regimens will vary.

Epidemiology

  • In the United States, there are over 626,000 hospital admissions a year for complicated urinary tract infections, comprising about 1.8% of all annual hospitalizations, with eighty percent of these being non-catheter related.[11]
  • Cohorts with more risk factors show an increased incidence of urinary tract infections. Risk factors include female gender, increasing age, diabetes, obesity, long-term catheters, and frequent intercourse (although UTI is not defined as a sexually transmitted infection).
  • Simple UTIs in nonpregnant immune-competent females have been estimated to occur with as high as 0.7 infections per person per year. Fifty percent of females will have at least one UTI at some stage in life.
  • Complicated UTI incidence is associated with specific risk factors. For example, there is a 10% daily risk of developing bacteriuria with indwelling bladder catheters and up to a 25% risk that bacteriuria will progress to a UTI.
  • About twenty percent of all bacteremias associated with healthcare originate from the urinary tract. The mortality associated with these urinary tract-based bacteremias can be up to 10%.[12]
  • Bacteriuria occurs in up to 14% of diabetic females but does not tend to occur with a higher frequency in diabetic males.
  • Asymptomatic bacteriuria tends to increase with age in females and is present in up to 80% of the elderly female population. It is rare among younger healthy males but can be present in up to 15% of older males.
  • About 9.4% of all urological inpatients developed a complicated UTI during their hospital stay.[13][14]
  • An increased incidence of UTI has been described in patients using dapagliflozin (SGLT2i) which treats diabetes by producing glycosuria.[15]
  • UTIs are the most common infections in renal transplant patients. Up to 25% of these patients will develop a UTI within the first year after a transplant.
  • UTIs are the seventh most common reason for a patient to be seen in an Emergency Department in the US, constituting over 1 million visits annually.[16][17] Of these, 22% (220,000) are considered complicated UTIs, and about 100,000 are admitted yearly.[16][17]

Pathophysiology

Biofilms

A biofilm is an encapsulated, structured microorganism colony that has created its own polymeric matrix for both protection and adherence to bodily structures, stones, or foreign bodies.[18] Biofilms also allow various pathogens of relatively low virulence can cause severe, potentially life-threatening infections.[9][10] Urinary stasis due to dysfunctional voiding or obstruction facilitates bacterial invasion of tissues and provokes a host response.[19] Foreign bodies such as stones and catheters are commonly associated with biofilms. Catheters, in particular, offer access to the urinary tract by bacteria, and the biofilm then protects the organisms from elimination. Multiple organisms are often involved in biofilms.[20] 

Most antibiotics cannot effectively penetrate biofilms and cannot treat bacteria located there.[21][22] Biofilm bacteria also tend to grow slowly, reducing the effectiveness of antibiotics that are more effective in rapidly dividing organisms.[23][24] While irrigation and free urinary flow can help minimize biofilm development, they cannot prevent it. The only effective therapy is to remove and replace the affected foreign body. Catheters that have been in place for 1 to 2 weeks or longer should be replaced before obtaining a urinalysis or urine culture to avoid contamination from the biofilm that has developed on the catheter. A complete biofilm will form on a urinary catheter in about two weeks. Patients with frequent CAUTIs may therefore benefit from more frequent catheter changes.

History and Physical

Given the frequency of urinary tract infections in hospitals, UTIs (especially complicated UTIs) remains a clinical entity causing considerable confusion, diagnostic uncertainty, and a source of significant inappropriate antibiotic prescriptions.

The most important clinical criteria for initially diagnosing a simple UTI are symptoms (increased urinary frequency, urgency, hematuria, dysuria, or suprapubic pain). There must also be an appropriate clinical scenario in which infection of the urogenital tract is the most likely explanation for these symptoms. It is appropriate to start empiric treatment with first-line antibiotics in this situation. A urine sample should also be sent for microscopy and culture before starting treatment, although that is not always possible. The urine sample would almost always show an abnormal red cell or white cell count, positive nitrites, and bacteria.

In general, any urinary tract infection that fails to resolve on first-line therapy or in a high-risk patient population should be considered a complicated UTI. Complicated UTI symptoms include all of those listed above, as well as additional findings such as fever, chills, flank pain, sepsis from a urological source, cystitis symptoms lasting >7 days, known multiple antibiotic resistance, permanent Foley or suprapubic catheters, acute mental status changes (especially in the elderly) and high-risk patient populations (pregnancy, immunocompromised state, renal transplant, abnormal urinary function as in patients with neurogenic or dysfunctional bladders, immediate post-urological surgery, renal failure, pediatrics, etc.).[8] 

Severe complicated urinary tract infections can present as undifferentiated sepsis or even septic shock.

Complicated urinary tract infections may also present with nonspecific symptoms, atypical presenting features (delirium in the elderly), signs mimicking an acute abdomen, be a trigger for precipitating diabetic emergencies such as diabetic ketoacidosis, and even present without any symptoms (asymptomatic bacteriuria in pregnancy).

Evaluation

A good quality urine specimen is vital in making the diagnosis. However, treatment must not be delayed if the clinical scenario strongly suggests a urinary tract infection.[25][26][27]

Most patients can provide a high-quality midstream urine sample with appropriate instructions. If that is not possible, a catheterized urine sample (indwelling catheter or a straight in-out catheter) may be used. Catheter insertion is not without some risk, and this must be weighed against the diagnostic advantage of having a urine specimen for analysis and culture. In general, obtaining a urine specimen for culture before initial antibiotic administration is recommended whenever possible and feasible. Most patients with complicated UTIs will demonstrate pyuria. The presence of white blood cell casts strongly suggests renal involvement.

Different normal white cell ranges depend on the urine sample, and the results should be interpreted accordingly.

Often, urine samples in prostatitis may not be diagnostic, especially if the patients have already been partially treated. A pre and post-prostate massage urine sample (also known as the four-glass test or even the shortened two-glass test) can improve the diagnostic yield in patients with prostatitis. In general, pelvic or perineal pain, difficulty in urination, failure of initial therapy, and rapid recurrence of symptoms suggest prostatitis.

Blood cultures are also useful in more severe septic presentations. A positive blood culture can sometimes also help corroborate a urine sample result and reduce any suspicion of contamination.

Some patients with clinical signs of a UTI may not demonstrate any urinary bacteria on culture. Patients with asymptomatic bacteriuria have no urinary symptoms but grow large numbers of bacteria on culture.[8] Urine with a cloudy appearance or foul odor may suggest infection, but these findings have not been clearly demonstrated to correlate with either bacteriuria or a UTI.[28]

Radiological investigations are not helpful in the initial diagnosis of most infections limited to the genitourinary tract. There should be sufficient clues from the history, physical examination, and laboratory results. Ultrasound and CT scans may sometimes be useful or even critical for diagnosing a perinephric abscess, urinary retention, hydronephrosis, and obstructive pyelonephritis from stones in septic patients. All septic patients and febrile patients who fail to respond to appropriate broad-spectrum antibiotics within 48 to 72 hours should undergo imaging to exclude complications such as abscesses, urinary retention, calculi, gas, and obstructive uropathy, pyonephrosis, and hydronephrosis. Renal ultrasonography is quicker, less expensive, and avoids radiation exposure to the patient but the CT scan is the definitive standard. It should be strongly considered in difficult or intractable cases, even if the ultrasound is negative, as the results can sometimes be life-saving.[29]

All patients who present with a complicated UTI, even the first presentation of ascending pyelonephritis in non-pregnant immune-competent females, should undergo a renal tract ultrasound at a minimum to evaluate for anatomical abnormalities hydronephrosis, stones, or other lesions. Since there is no reliable clinical method to rule out urinary obstructions in complicated UTIs (such as a stone), the treating physician's responsibility is to do so with an ultrasound or CT scan.[30] 

Older patients, especially those with dementia, are at increased risk for complicated UTIs.[31] Dementia can cause a decline in personal hygiene and increase various voiding issues. There is also an increased risk for urinary catheterization. Diagnosis can be more difficult as patients with dementia may present with altered mental status, increased confusion, or agitation instead of the usual lower urinary tract symptoms.[32]

Treatment / Management

As UTI can present with severe, life-threatening sepsis and multiorgan involvement. Resuscitation often precedes definitive treatment. The severely septic patient might need aggressive fluid resuscitation and broad-spectrum antibiotics administered in the emergency department. Antibiotic choices should always be made according to local bacterial resistance patterns and guidelines.[33][34][35][36]

Patients presenting with septic shock may not respond to fluid resuscitation alone, and there should be a low threshold to consider vasopressor support in light of a poor initial response to fluids.[8][37][38] On the other hand, nonseptic stable patients may be treated as outpatients.

Broad-spectrum, empiric antibiotics should always be switched to a targeted narrow-spectrum antibiotic, if possible, once culture results are available. Initial broad-spectrum choices tend to be penicillins or beta-lactams, cephalosporins, fluoroquinolones, and carbapenems (especially if dealing with an extended-spectrum beta-lactamases (ESBL) organism). The specific choice will depend on the individual hospital's microbiological spectrum and antibiogram.[39]

Patients who present with repeat infections may also be initially treated as per their previous urine culture results until new cultures are available. Imaging to look for a source of infection such as an abscess or stone should be done with relapsing infections that involve the same organisms.[40] Patients who presented initially with hematuria should be checked for urinary blood again after the infection has been successfully treated.

Treatment response should be evident in 24 to 48 hours in most cases. A poor response may indicate an inappropriate antibiotic selection, polymicrobial infections, atypical infections, hydronephrosis, obstructing stone causing pyonephrosis, complications such as a perinephric abscess or emphysematous UTI, fluid collections such as urinary retention or anatomical lesions leading to poor response (nephrocalcinosis acting like an infective nidus, obstructive urinary tract lesions, urinary calculi, or fistulas). A temporary Foley catheter, to guarantee good bladder drainage, is often recommended for these patients if they are septic and particularly if they have increased post-void residual volumes.

The duration of antibiotic therapy in complicated UTIs is typically 10 to 14 days. While technically, any UTI in a male is considered a "complicated UTI," many experts will treat what appears to be an unambiguous lower urinary tract infection in an otherwise healthy man with no known bladder dysfunction, stones, or other high-risk factors the same as a simple UTI with first-line antibiotic agents such as fosfomycin, trimethoprim-sulfamethoxazole, or nitrofurantoin. In recurrent infections, especially if the same organism is encountered, prostatitis should be suspected and treated accordingly.

The vast majority (97%) of patients with mild or moderate pyelonephritis without major comorbidities can be managed as outpatients after initial parenteral antimicrobial therapy and a short period of observation.[41] 

Men presenting with recurrent UTIs or bacterial prostatitis may require four to six weeks or longer to completely eradicate their infecting bacteria. Men with benign prostatic hyperplasia (BPH) and recurrent or intractable urinary tract infections should be considered for surgical therapy.[42] Nitrofurantoin is not generally recommended in complicated UTIs in men due to poor tissue penetration, particularly in the kidneys, testicles, and prostate.

Failure to respond to appropriate antibiotics should suggest a possible urinary blockage such as obstructive pyelonephritis. In such cases, a renal ultrasound or non-contrast CT scan should be done for diagnosis and immediate surgical drainage performed if an obstructed, infected kidney is found (either by double J stenting or a percutaneous nephrostomy).

The success of treatment involves proper antibiotic selection, appropriate dosage adjustment, and correct duration of therapy. Eradication of high-risk factors whenever possible is also warranted, such as removing infected stones or indwelling catheters.

Prophylactic antibiotics are seldom recommended routinely due to the rapid development of bacterial resistance. When the clinical situation requires prophylaxis, nitrofurantoin is usually the preferred agent at a 50 mg. daily dose, generally taken before bed.[43][44]

Patients with permanent Foley catheters or suprapubic tubes should avoid prophylactic antibiotics and only be treated when symptomatic. More frequent changes of urinary catheters are recommended in chronically catheterized patients with recurrent or frequent infections. Patients with long-term Foley catheters will tend to have somewhat fewer infections if converted to a suprapubic tube.[45] If a patient with a catheter develops an infection, changing the catheter is recommended to eliminate the contaminated biofilm and reduce recurrences.[8]

Mandelamine is a twice-daily medication that, in acidic urine, is converted to formaldehyde which is a potent urinary antiseptic. This can be useful in patients with multi-drug resistant infections or persistently elevated post-void residuals instead of prophylactic antibiotics.[46] It is often given together with ascorbic acid (1,000 mg twice daily) to help maintain urinary acidity, which is necessary for the production of formaldehyde.[47] It should not be given with sulfonamides as it can cause a precipitate. It is not recommended for patients with a glomerular filtration rate <10 mL/min.

Cranberry supplements have been studied with conflicting evidence of any efficacy in treating complicated or recurrent UTIs.[48][49][50] Probiotics have not shown any significant benefit vs. placebo in treating complicated UTIs.[51]

Fosfomycin has shown good activity in patients with urinary tract stones.[52][53] It showed significant penetration inside stones and was more effective than cefuroxime for this purpose.[53] Fosfomycin is also being used parenterally as empiric therapy for complicated UTIs in some parts of the world but not yet in the US.[54] It is suggested that its use be limited to cases where carbapenems cannot be used in order to maintain efficacy.

Intermittent bladder instillations of an antibiotic or antiseptic solution have been used successfully in recurrent or relapsing UTI patients with renal failure, oliguria, pyocystis, or just frequent recurrences, especially in patients already performing intermittent self-catheterization.[55] The most commonly used antimicrobial for this purpose is a gentamicin solution.[55] The recommended dosage is to instill 30 to 60 cc of a 480 mg of gentamicin solution in 1 liter of normal saline after initially draining the bladder.[56] Gentamicin has no significant systemic absorption when introduced in this fashion, so that it can be used regardless of renal function. While gentamicin is the recommended agent initially, if it is not available, tobramycin, hyaluronic acid, Lactobacillus rhamnosus, povidone-iodine solution, or Neosporin can be used as alternatives.[55][57] 

Neomycin alone showed no efficacy in controlling bacteriuria, but chlorhexidine and povidone-iodine have been shown to reduce UTIs and bacteriuria.[55] Neosporin can also be used as a short-term (10-day) continuous bladder irrigation with a three-way Foley catheter.[58] Bladder antibiotic instillations are particularly useful in dialysis and anuric patients because they are not dependent on renal excretion of antibiotics. Interestingly, heparin bladder instillations have also shown some activity in reducing recurrent UTIs, most likely by providing a mucopolysaccharide coating to the urothelial bladder surface.[59]

Empiric Initial Antibiotic Therapy for Patients With Urosepsis

Initial antibiotic selection in septic or systemically ill patients prior to receiving specific culture results will depend on individual patient characteristics and local bacterial resistance antibiograms. For example, fluoroquinolones are generally not recommended for empiric use if the local resistance is 10% or higher. A discussion with a local infectious disease specialist can help determine the best initial empiric approach for that specific local community. In general, parenteral antibiotics are recommended for patients with systemic or severe illness at least until urine culture results can guide the antibiotic selection. If no such antibiotic is apparent, consider an infectious disease consultation. 

  • Ceftriaxone or piperacillin-tazobactam can be used in patients who are less severely ill. (Piperacillin-tazobactam is preferred if Enterococcus, Staphylococcus, or Pseudomonas is suspected due to its greater activity.)
  • Vancomycin, linezolid, or daptomycin should be added if methicillin-resistant Staphylococcus aureus (MRSA) is suspected.
  • If Pseudomonas is suspected, piperacillin-tazobactam, fluoroquinolones, cefepime, or ceftazidime should be used.
  • Parenteral fosfomycin has also been used for complicated UTIs and has good activity against many highly resistive organisms such as ESBL-producing bacteria (not available in the US).
  • Quinolones should be considered whenever the local resistance patterns allow.
  • Aminoglycosides are usually reserved for patients where other less nephrotoxic drugs cannot be used due to resistance or allergy. 
  • For maximum coverage in the sickest patients, consider using a carbapenem with anti-pseudomonal activity such as imipenem (which will cover extended-spectrum beta-lactamase-producing organisms) and vancomycin for methicillin-resistant Staphylococcus aureus (MRSA). (Not ertapenem as it generally has little activity against Pseudomonas.)

Newer Antibiotic Agents For Multi-drug Resistant Infections

The development of multiple drug-resistant organisms has prompted the investigation of older antimicrobials (primarily aminoglycosides and tetracyclines) as well as the development of a number of new antibiotics and combinations such as aztreonam/avibactam, cefepime-enmetazobactam, cefepime-zidebactam, eftazidime/avibactam, ceftazidime/avibactam, cefiderocol, ceftolozane/tazobactam, eravacycline, glycylcyclines, meropenem/vaborbactam, imipenem/relebactam, omadacycline, plazomicin, and tebipenem.[60][61]

Ceftazidime/avibactam combines a potent third-generation cephalosporin with a beta-lactamase inhibitor designed to treat complicated UTIs. It was FDA-approved in 2015 and is intended for use where other medications are not likely to be effective due to resistance.[62][63]

Cefiderocol is a new, unique, FDA-approved synthetic siderophore-conjugated cephalosporin antibiotic that can be used for complicated UTIs involving highly resistant organisms. It uses the bacterial cell iron transport mechanism to facilitate the cellular introduction of drugs which provides very high intracellular concentrations of medications.[64] It is well tolerated and active against many multi-drug resistant organisms, including those resistant to carbapenem antibiotics.[65] It is intended only for limited use as a last-resort option for multiple drug-resistant infections. While promising, some bacterial isolates have already demonstrated resistance, so usage is limited.[64]

Meropenem-vaborbactam enhances the activity of meropenem against organisms that manufacture Klebsiella pneumonia-producing carbapenemase (KPC). It is FDA-approved for complicated UTIs, including pyelonephritis in susceptible organisms.[66][67]

Plazomicin is a unique, FDA-approved aminoglycoside specifically developed for multi-drug resistant organisms, including those that produce aminoglycoside-modifying enzymes (AMEs), extended-spectrum beta-lactamases (ESBLs), and carbapenemases. Standard aminoglycosides have limited activity against bacteria that produce AMEs, and carbapenem-resistant organisms are emerging. Plazomicin was chemically designed to block the activity of most AMEs. It is effective against 90% of coliform bacteria except for Proteus mirabilis and Morganella morganii. It is also effective against 90% of Escherichia coli, and Klebsiella pneumoniae isolates, whether ESBL producing or not. Like other aminoglycosides, it has some nephrotoxicity.[68][69][70]

Tebipenem is an oral carbapenem that has shown equivalence (non-inferiority) to parenteral ertapenem in treating susceptible organisms causing pyelonephritis and other complicated urinary tract infections.[71] It will probably be the first available oral carbapenem when it receives FDA approval, expected in the second half of 2022.

Special Patient Risk Groups

Catheter-Associated UTIs (CAUTIs)

The Infectious Disease Society of America (IFDSA) defines a CAUTI as:

  • Having an indwelling catheter for at least two days after initial insertion.
  • One UTI sign or symptom (fever, chills, suprapubic pain, costovertebral angle tenderness, flank pain, or urinary symptoms (dysuria, urgency, or frequency)). (Older patients may present with altered mental status or hypotension).
  • Urine culture with at least 1,000 CFU/mL of a single bacterial species.[72][73][74]

The US Centers for Disease Control and Prevention: National Health Safety Network defines CAUTI a little differently. They include the presence of a fever, suprapubic tenderness, or costovertebral angle pain, along with a colony count >100,000 with no more than two different organisms.[75] This definition does not take into account other potential sources of fever, so many experts feel this definition is less useful and tends to overestimate the actual CAUTI rate.[76] Therefore, the IFDSA definition is usually preferred in clinical practice.

Between 15% and 25% of all hospitalized patients will have a urinary catheter during some period during their hospital stay. It is estimated that 21% to 50% of such catheters are unnecessary and do not meet guidelines for initial placement.[77] The US Centers for Disease Control and Prevention has estimated that from 17% to 69% of all CAUTIs are preventable with optimally applied infection control measures. This means that up to 9,000 deaths and 380,000 infections a year are potentially avoidable!

Twenty percent of hospital-acquired bacteremias in acute care facilities are attributed to urinary catheterization, and fifty percent in long-term care centers.[78][79] According to the National Healthcare Safety Network (NHSN); Centers for Disease Control and Prevention (CDC), this amounts to about 450,000 CAUTI events annually with 13,000 deaths and a total annual cost of $340 to $450 million.[80] 

Catheterized patients are expected to have bacteriuria due to colonization and the development of biofilms. The rate of bacterial colonization is approximately 3% to 10% per catheterization day. This translates into 100% bacterial colonization after the first 30 days. Besides the duration of Foley catheterization, other identified risk factors include female gender, older patient age, diabetes, bacterial colonization of the drainage bag, urethral catheterization (compared to suprapubic), and errors in sterile catheter insertion procedures or maintenance care.

Proper urine specimen collection is important in catheterized patients suspected of a CAUTI to avoid culturing of the biofilm. If possible, the optimal method is to remove the catheter and have the patient urinate for the specimen. If this is not possible, the catheter should be replaced prior to specimen collection. If it is necessary to collect a specimen without removing the catheter, the use of a designated drainage system side port access is suggested. If none of these techniques is possible, then the last resort is to separate the catheter from the drainage system. Urine cultures should not be obtained from the drainage bag.[81] For patients with a condom catheter, a clean-catch midstream specimen is preferred.[82] If this is not obtainable, the specimen can be collected from a new condom catheter after carefully cleaning the glans.

Bacterial inoculation of the bladder in catheterized patients may be extraluminal (through the external biofilm) or intraluminal (from catheter blockage or contamination of the drainage bag). Extraluminal is the more common method (66% vs. 34%).[83]

The most common organisms causing CAUTIs include E. coli (24%), Candida or yeast (24%), Enterococcus (14%), Pseudomonas (10%), and Klebsiella (10%).[84] Many such organisms are becoming increasingly resistant to antibiotics, including fluoroquinolones, third and fourth-generation cephalosporins, aminoglycosides, and even carbapenems.[84]

Routine instillation of various antiseptics into the urinary drainage bags can help reduce calcium phosphate precipitates and decrease bacterial counts. Hydrogen peroxide 3% and chlorhexidine have shown minimal to no effect in reducing urinary bag bacteriuria.[85] The most effective agents are 1/4% acetic acid, diluted household white vinegar (1:3 dilution), and household bleach (1:10 dilution).[86][87] Diluted vinegar is the most effective in dissolving calcium phosphate grit, precipitate, and debris which tends to clog catheters and bags and also lowers the bacteria count. The diluted bleach solution is the most effective in controlling bacterial growth, but none of these measures has been proven to reduce CAUTIs. Therefore, the Infectious Diseases Society of America (IDSA) guidelines advise against the routine addition of antiseptics to the drainage bag of catheterized patients because of a lack of proven efficacy.[73] Surprisingly, many of the recommended, obvious, or suggested catheter-related interventions have failed to demonstrate clear evidence of reductions in CAUTIs, including:

  • Sterile technique for catheter insertion
  • Use of antiseptic or antibiotic ointments for routine meatal care
  • Antiseptic filters and anti-reflux mechanisms built into the urinary drainage bags
  • Use of dual-chambered drainage bags
  • Routine bladder or catheter irrigation
  • More frequent changes of the urinary drainage bags (every 7 to 14 days)
  • Placing antiseptic solutions in the drainage bags[87][88][89]

The most effective strategy in reducing CAUTIs is to avoid indwelling catheters whenever possible, discontinue them as soon as clinically feasible, and use optimal sterile placement techniques and maintenance procedures.[79] 

Additional helpful measures to minimize CAUTIs include:

  • Mandatory educational programs for all healthcare workers involved in urinary catheter insertion or care
  • Strict adherence to guidelines for indwelling catheter placement
  • Using alternative urinary control measures (pads, condom catheters, mechanical suction devices, suprapubic tubes, Cunningham clamps, intermittent catheterization, etc.) whenever possible
  • Use of a daily checklist to justify continuing all indwelling catheters
  • Implementing automatic catheter removal orders at the time of initial Foley insertion unless specifically instructed otherwise and justification is provided
  • Strict adherence to guidelines for diagnosis and treatment of CAUTIs to avoid overtreating asymptomatic bacteriuria
  • Minimizing unnecessary urine cultures, which often produce positive cultures even in uninfected patients that are strong temptations for inappropriate antibiotic use
  • Follow guidelines for correct specimen collection procedures; when necessary, urine cultures are performed
  • Carefully investigate all alternative sources of infections and fevers before diagnosing a CAUTI
  • Never using indwelling catheters solely for incontinence

Purple bag urine syndrome is a rare disorder that occurs in patients with long-term catheters, usually older women with constipation. Dietary tryptophan is broken down in the intestinal tract to indole, which is absorbed and converted into indoxyl sulfate by the liver. This is eventually excreted into the urine, where the indoxyl sulfate is converted by bacterial enzymes (in alkaline urine) to indigo (blue) and indirubin (red), which cause the intense purple color.[90][91][92] Treatment is generally to change the catheter and bag, treat constipation, avoid dehydration, and reassure the nursing staff.  

Spinal cord injury patients with catheters offer unique challenges in diagnosis, prophylaxis, and treatment of CAUTIs. Many of these patients require permanent or intermittent catheterization, which leads to a high incidence of asymptomatic bacteriuria that does not require treatment.[93] Impaired patient sensation may delay the appearance of pertinent, relevant symptoms. The development of non-specific symptoms such as fever, along with bacteriuria and positive urine cultures, will often lead to a diagnosis of CAUTI even when the actual infection may be elsewhere. This leads to the frequent overdiagnosis and overtreatment of CAUTI in this patient population.[94] 

It is estimated that at least 35% of spinal cord injured patients diagnosed and treated for CAUTI actually have only asymptomatic bacteriuria.[95] To facilitate diagnosis, it has been suggested that increased spasticity and autonomic dysreflexia be included as potential symptoms of a CAUTI in this population, but it is unclear how clinically useful this will be.[73] 

The general principle of early catheter removal does not necessarily apply to spinal cord injured patients who may not have a suitable alternative for safe bladder drainage. Inappropriate Foley catheter removal puts them at risk for urinary retention, vesicoureteral reflux, renal failure, autonomic dysreflexia, and sepsis. Clean intermittent self-catheterization is safe, effective, and associated with a lower incidence of bacteriuria and CAUTIs but there are still increased risks of infection, false passages, urethral strictures, bladder overdistention or retention, and a heavy reliance on caregivers for logistical support and supplies.[96][97] 

There is some evidence that long-term use of nitrofurantoin and D-mannose prophylaxis can effectively reduce CAUTI in spinal cord injured patients.[98][99] The use of silver and hydrophilic coated catheters also appeared to help reduce CAUTIs, but the studies were small and not considered definitive.[100][101] Cranberry supplements and other nutraceuticals have demonstrated either no activity or conflicting results in reducing CAUTIs in this population.[102][103]

A guidelines-based model for ordering urine cultures and antibiotics has proven successful in significantly reducing overdiagnosis and overtreatment of asymptomatic bacteriuria in long-term catheterized patients by over 70%.[104][105] 

UTIs in Pregnancy 

Between 2% and 7% of pregnant women will develop asymptomatic bacteriuria, usually early in their pregnancy.[93] Those with a history of prior UTIs, diabetes, a larger number of prior deliveries, and lower socioeconomic status are at higher risk.[106] Without treatment, up to 35% will progress to a symptomatic UTI and/or pyelonephritis during the pregnancy.[107] Most studies suggest that untreated bacteriuria during pregnancy is associated with an increased risk of low birth weight, prematurity, pre-eclampsia, and perinatal mortality.[106][108][109] Pyelonephritis has also been associated with poor pregnancy outcomes, particularly prematurity.[110] Treatment of asymptomatic bacteriuria and cystitis would generally include 3-7 days of amoxicillin-clavulanate, cephalexin, cefpodoxime, or a single dose of fosfomycin.[111] Nitrofurantoin and sulfamethoxazole/trimethoprim may also be used but not during the first trimester to close to term.[107][112][113]

Pyelonephritis during pregnancy can be challenging and generally requires hospitalization. Standard therapy would include ceftriaxone, cefepime, and ampicillin/gentamicin. Aztreonam is suggested if there is a beta-lactam allergy. Treatment can be adjusted after culture reports are available. More severe infections may require piperacillin/tazobactam, meropenem, ertapenem, or doripenem.[114] Aminoglycosides should be used cautiously due to potential fetal ototoxicity.

UTIs in Renal Failure and Dialysis

It is well known that chronic renal disease will affect decreased urinary excretion of antibiotics, but other factors also play a role.[115] There is reduced urinary antibacterial function, uremic immunosuppression, lower antibacterial levels within the bladder and renal tissues, inhibition of urothelial antimicrobial functions, and possibly reduced urinary volume.[8][116][117][118] People with diabetes who have glucosuria will demonstrate increased bacterial adherence to the detrusor urothelium as well as decreased neutrophil efficacy.[119]

The diagnosis of a UTI in dialysis patients can be tricky as 30% to 40% will normally demonstrate pyuria even without any infection.[120] The diagnosis therefore also requires symptoms and a positive urine culture. Infections are often related to catheterization, and Candida is the most common organism in this population.[121]

Antibiotics need to be used cautiously in patients with severe or end-stage renal failure. Nitrofurantoin and tetracyclines (other than doxycycline) should be avoided. Aminoglycosides can be used cautiously, as they are potentially nephrotoxic. A number of other antibiotics, such as trimethoprim-sulfamethoxazole, trimethoprim alone, cephalexin, second and third-generation cephalosporins, and fluoroquinolones can generally be used at a reduced (usually 50%) dosage.[122][123][124] Ertapenem has a renal failure and dialysis-suggested dosing schedule, but neurotoxicity has been reported even when using the recommended dosages.[125] Moxifloxacin can be used in renal failure but will not achieve adequate urinary concentrations and therefore cannot be recommended for UTIs.

A number of antibiotics generally do not require any adjustment in renal failure. These include:

  • Azithromycin
  • Ceftriaxone
  • Clindamycin
  • Doxycycline
  • Fosfomycin
  • Linezolid
  • Nafcillin
  • Rifampin

Intermittent bladder instillations of antibiotics (gentamicin, tobramycin, amikacin, neomycin/polymyxin B/bacitracin) or antiseptic (povidone-iodine) solutions can be helpful in patients with renal failure who have minimal urinary volume, are already performing intermittent self-catheterization, or where alternative means have not been successful.[55] Antibiotic bladder instillations (intermittent or continuous) can also be used for pyocystis, defined as a collection of pus in the bladder of an anuric patient.[126][127][128]

UTIs in Renal Transplants

The diagnosis of a complicated UTI can sometimes be difficult in renal transplant patients. Symptoms may be subtle and non-specific such as nausea or unusual fatigue. Fever and palpable tenderness over the graft site is more likely to be associated with a UTI than with acute rejection. Therefore, renal transplant UTI patients with systemic signs of infection, such as fever or graft tenderness on palpation, should have blood cultures taken as well as standard urine cultures. This is because about 9% will ultimately show positive for bacteremia.[129] A diagnostic renal biopsy should be considered in questionable cases of pyelonephritis in renal transplant recipients or when a UTI is associated with graft dysfunction, especially during the first six months after the transplant.[130] (Patients with acute rejection are more likely to have azotemia, worsening proteinuria, and hypertension.)

All symptomatic UTIs in renal transplant patients are considered complicated UTIs. Morbidity and mortality from UTIs are increased in kidney transplant patients as the required immunosuppression increases infection risk and interferes with therapy.[131][132] The current 1-year mortality from infectious complications in renal transplant recipients is now less than 5%, having dropped from almost 50% historically, mostly due to advances in surgical techniques and post-operative care.[133] 

UTIs are most common during the first year after transplantation and will occur in about 25% of transplant recipients during that time.[129][134] About 7% of renal transplant recipients will develop recurrent UTIs, which is associated with an increased risk of multiple antibiotic resistance, transplant failure, and death.[135] Ascending urinary tract infections with the early progression to frank pyelonephritis is more common in renal transplant recipients as they have very short ureters and will often lack an effective anti-reflux mechanism. The incidence of acute pyelonephritis also appears to be related to the frequency of rejection episodes and recurrent UTIs. Renal transplant patients who develop pyelonephritis are more likely to develop increases in serum creatinine along with a decrease in creatinine clearance which is often persistent.[136] 

Screening for asymptomatic bacteriuria immediately post-transplantation for the first 90 days is controversial as many experts recommend it while others do not.[137][138] There is no good data suggesting that screening or treating asymptomatic bacteriuria during the first three months after transplantation is helpful, so this remains a judgment call by the transplant team. If screening is done, microscopic urinalyses with urine cultures are recommended at 2, 4, 8, and 12 weeks after surgical transplantation.[139] 

Screening for asymptomatic bacteriuria after the first three months is not recommended as treatment beyond this point has not been effective in UTI prevention or graft preservation and will potentially lead to the unnecessary use of antibiotics and increased bacterial resistance.[140][141] Historically it was thought that graft and patient survival were not affected by adequately treated complicated UTIs, but more recent data suggests that acute and recurrent graft pyelonephritis are significant risk factors for decreased long-term graft and patient survival.[142][143] 

Post-transplantation risk factors for UTIs include female gender, advanced patient age, longer time on dialysis prior to transplantation, recurrent UTIs in the recipient prior to transplantation, polycystic kidney disease, Foley catheterization, ureteral stent placement, use of a deceased-donor transplant, and urinary tract obstruction or dysfunction.[144][145][146] 

Antibiotic UTI prophylaxis is commonly used for the first 6 to 12 months post-transplantation.[147] Some experts continue the prophylaxis indefinitely.[148] Trimethoprim-sulfamethoxazole is the most commonly used prophylactic agent, but there are concerns about increasing bacterial resistance. Cephalexin and norfloxacin prophylaxis has been used successfully in patients unable to take trimethoprim-sulfamethoxazole.[149] Methenamine hippurate (1,000 mg twice daily) with or without vitamin C (1,000 mg twice daily) has also been used successfully for UTI prophylaxis in renal transplant patients.[150][151] Further, it can be safely used in patients with a creatinine clearance of >10 mL/min but should not be used together with sulfa drugs due to the potential formation of bladder precipitates. Fosfomycin has been used effectively in addition to standard trimethoprim-sulfamethoxazole therapy before urologic procedures and for UTI/asymptomatic bacteriuria treatment in this population.[141][152]

There is an increased incidence of Klebsiella pneumoniae being the infecting organism in renal transplant patients than in the general population.[132] Besides Escherichia coli and Klebsiella pneumoniae, other common pathogenic bacteria include Enterobacter cloaca. Pseudomonas aeruginosa, and Enterococcus. Due to reduced host resistance factors, treatment is typically 14 to 21 days. Patients suspected of having a UTI but demonstrating a negative urine culture should be tested for Corynebacterium urealyticum, which requires special culture media for identification.[153]

Simple cystitis is typically treated for 10 to 14 days. (Nitrofurantoin may now be used if the GFR is 30 mL/min or more.)[154][155][156] The optimal duration of antibiotic therapy for complicated UTIs is unclear, but the standard treatment period is 14 to 21 days, although this can be extended. Infected cysts, for example, may need 4 to 6 weeks. Trimethoprim-sulfamethoxazole would be less ideal if the local resistance prevalence is reported as 20% or more.[157][158][159]

Selective imaging can be helpful in some renal transplant patients with UTIs. The initial test is usually ultrasonography. Patients with polycystic kidney disease may have an infected cyst which can be challenging to identify. Such patients often have flank pain related to the infected renal cyst rather than graft discomfort. In such cases, a CT-PET scan can be beneficial.[160][161][162] If the ultrasound is negative, a non-contrast CT scan is a reasonable next step, especially in patients with a history of nephrolithiasis. (While contrast is useful, it also is potentially nephrotoxic and cannot be used safely in patients with elevated serum creatinine levels.) Voiding cystourethrograms can be used to identify reflux, and urodynamics will diagnose bladder dysfunction and outflow obstruction.

Specific Infections

Emphysematous cystitis is a lower urinary tract infection of the bladder where there is gas within the bladder wall caused by gas-producing bacteria. Such gas-forming bacteria are usually Escherichia coli or Klebsiella pneumonia. (Other organisms that can produce gas include Proteus, Enterococcus, PseudomonasClostridium, and (rarely) Aspergillus and Candida.) Rarely emphysematous cystitis has been caused by infectious colitis with no clinical signs or evidence of a UTI.[163] It typically develops in people with diabetes, females more than males, the elderly, and those with some element of urinary obstruction. High glucose levels in the bladder wall tissue certainly play a part, but the precise etiology of emphysematous cystitis is not well understood.[164] The mean age of presentation is about 68 years, and about 50% of patients will have two or more significant comorbidities. About one-third will present with sepsis, 25% with abdominal pain, 17% with UTI symptoms, 6% with hematuria, and 8% will be asymptomatic but incidentally detected on an imaging examination.[165] While the diagnosis can sometimes be made by ultrasound or plain KUB X-ray, most are identified by CT scans. Treatment is primarily with culture-specific antibiotics, bladder drainage, supportive care, and elimination of risk factors. Ninety percent of cases can be managed conservatively, and only 5% to 10% will require some type of surgery.[165] 

Emphysematous pyelonephritis is a particularly debilitating necrotizing infection of the kidney characterized by gas within the renal parenchyma or perinephric space. It is typically diagnosed on a CT scan. The vast majority of patients with the condition are diabetic (95%), and it is six times more common in women than in men. It is also associated with renal failure, obstruction, polycystic kidneys, and an immunocompromised state.[166][167] Poor prognostic factors include azotemia, thrombocytopenia, shock, hyponatremia, confusion, and hypoalbuminemia.[168] Treatment includes renal drainage, blood sugar control, and parenteral antibiotics, typically for 3 to 4 weeks. Emergency nephrectomy is being recommended less often than previously as early surgery generally has a negative effect on outcomes. Surgery is now generally recommended if there are multiple risk factors in a non-functioning kidney or the patient is not responding to conservative measures.[168][169] 

Pyonephrosis (obstructive pyelonephritis) describes an acutely infected, hydronephrotic kidney where there is usually an obstructing calculus. Sepsis rapidly ensues unless the obstruction is quickly relieved by drainage from a double-J stent or percutaneously. These patients are generally quite ill with high fevers, chills, and flank pain. They tend to rapidly progress to urosepsis, shock, and death. The urine may sometimes not show any obvious signs of infection if there is complete obstruction of the affected renal unit. Ultrasonography can identify the problem quickly, but a non-contrast CT scan will more clearly show the level and nature of the obstruction. A CT scan can also show other pathologies such as various cancers, retroperitoneal fibrosis, and other disorders. Management includes fluids and antibiotics, but the critical component is urgent drainage of the hydronephrotic, infected kidney.[169][170] Known risk factors include a history of nephrolithiasis, diabetes (especially poorly controlled), elevated CRP, positive urinary nitrites, larger stone size (>5 mm), and peri-renal fat stranding.[171] 

Definitive treatment of the obstruction is usually delayed until the immediate infectious process has been controlled. Percutaneous nephrostomy is usually preferred for the most severe cases as there is minimal manipulation of the infected stone and no risk of possible failure to bypass the obstruction cystoscopically from a retrograde approach.[172] A particularly large collection of stones should also be initially drained and managed percutaneously.[170][173] It has been suggested that definitive stone surgery be conducted within three weeks of ureteral stent placement.[174] Complications, specifically reduced post-operative urinary tract infections, are minimized if the stone removal operative time is 75 minutes or less.[174]

Xanthogranulomatous pyelonephritis is a chronic renal infection where the kidney is almost always obstructed and hydronephrotic with necrosis and severe inflammation of the renal parenchyma. It is often seen in patients who are immunocompromised and/or diabetic. It is diagnosed most reliably by CT scan. It can sometimes be mistaken for renal cell carcinoma as foamy lipid-infused histiocytes (xanthoma cells) can appear to be cancer cells on biopsy.[175][176] One way to differentiate them is that xanthogranulomatous pyelonephritis (xanthoma) cells will stain positive for periodic acid Schiff.[177] Initial treatment is with antibiotics and drainage, but surgical excision (focal or, more often, total) is usually necessary for cure.[176][177] Laparoscopic and robotic surgery is possible but can be difficult even for experienced surgeons, so an open approach is usually recommended.[176]

Other specific infections involving the urinary tract are best found in our companion articles on those specific topics. These would include tuberculosis, candidiasis, schistosomiasis, filariasis, prostatitis, orchitis, epididymitis, necrotizing fasciitis, renal and scrotal abscesses, etc.

New diagnostic methods and guideline implementation guides are being developed to hasten proper diagnosis, minimize inappropriate antibiotic use, and improve antimicrobial selection accuracy. These new aides include computer programs with artificial intelligence algorithms, new classes of biomarkers, and cell-free DNA analysis, among others. New catheter materials and coatings, as well as innovative bacterial growth interference agents and anti-infective vaccinations for high-risk populations, are being studied. Entirely new classes of antibiotics are being designed and created.[178] Bacteriophages (viruses that attack only specific bacteria) have already been used anecdotally but successfully on a very limited basis for highly resistant infections.[94][179][180] Bacteriophages can not only prevent the formation of biofilms but can produce polysaccharide depolymerase, which allows for phage penetration deep into existing biofilms where antibiotics cannot reach.[181][94] They are also unaffected by bacterial antibiotic resistance mechanisms.[94][181]

Differential Diagnosis

  • Acute pyelonephritis
  • Bladder cancer
  • Chlamydial genitourinary infections
  • Cystitis
  • Herpes simplex
  • Interstitial cystitis
  • Pelvic inflammatory disease
  • Prostatitis
  • Urethritis
  • Vaginitis

Prognosis

The FDA recommends the use of dual primary endpoints to determine the eradication of complicated UTIs: both clinical response (symptom resolution with no new UTI symptoms) AND a microbiological (urine culture) response to <1,000 CFU/ml.[8] 

Complications

Inadequate treatment of complicated urinary tract infections will increase the likelihood of an early recurrence or even an outright failure of therapy. The infection can spread to other organs, cause an abscess, or progress to sepsis.

Pearls and Other Issues

Diagnostic Pitfalls

Urinary tract infections are primarily a clinical diagnosis, and expert opinion should be sought before initiating treatment of an isolated positive result in an otherwise asymptomatic patient, the only exception being asymptomatic bacteria.

Quite often, clinicians end up treating the positive culture report rather than a genuine urinary tract infection. Most often, a positive culture in an asymptomatic patient can be traced to poor sampling technique.

Another confusing scenario is that of a septic, delirious, elderly patient who is unable to provide a history or demonstrate adequate examination signs to help localize a septic source. Quite frequently, these patients are treated as having a presumed UTI in the absence of a clear alternative septic source.

UTI-associated radiological changes can sometimes take several months to resolve and must be interpreted with care in cases of recurrent or persistent infections.

UTI must be considered a differential diagnosis when evaluating a patient with a pelvic inflammatory disease or an acute abdomen.

Male patients with urinary tract infections should also be screened for sexually transmitted infections.

Interstitial cystitis is frequently misdiagnosed and treated as a UTI and must be considered as an alternative diagnosis in patients who keep presenting with cystitis symptoms without positive cultures.

"Sterile pyuria," with persistent urinary WBCs but negative standard urine cultures, could indicate tuberculosis which requires special cultures. 

Bacterial infections only tend to account for 80% of all urinary tract infections, and antibiotics may sometimes prove ineffective.

Spinal cord injury patients with a UTI may present with increased spasticity or autonomic dysreflexia.

Since there is no way to clinically distinguish obstructive pyonephrosis (a surgical emergency) from acute pyelonephritis (treated medically), consider reasonable urinary tract imaging (ultrasound, CT scan) in all cases of presumed pyelonephritis; especially in those who fail to improve on appropriate antibiotics.

Management Pitfalls

Frail, elderly, or debilitated patients with nonspecific signs such as unexplained falls or change in mental status are often suspected of having a UTI. While this is correct, such nonspecific changes are not reliable predictors of a UTI, and antibiotics may not help in these situations unless urine studies confirm the UTI.[182][183]

Multidrug-resistant infections are becoming a major source of in-hospital mortality and morbidity. Suppressive antibiotic regimens are sometimes used in poorly responding or resistant cases. A dedicated infectious disease team should optimally guide these presentations, as long-term suppressive antibiotics come with a unique set of complications.

Long-term antibiotic prophylaxis must also be used with caution, as it will increase the risk of resistance and change the susceptibilities of colonized organisms. On occasion, residual urinary symptoms may take several months to resolve or might never resolve (especially in patients with indwelling catheters, post-prostatectomy cases, post bladder surgery, or radiotherapy) and do not always indicate a genuine urinary tract infection.

Long-term prophylaxis with nitrofurantoin is associated with hypersensitivity pneumonitis. Patients should be counseled accordingly.

It helps to identify predisposing factors for the infection and correct them if possible. For example, a diabetic patient would benefit from improving glycemic control. Renal tract anatomic abnormalities should be assessed to see if an intervention is appropriate (renal calculi, BPH, ureteric strictures). Immunocompromising factors may be addressed if possible (steroids, HIV). Finally, nephrotoxic medications should be avoided whenever possible in patients with any degree of renal compromise. If unavoidable, care should be taken to use the optimal dose and duration of therapy with regular, routine monitoring of renal function.

Finally, do not hesitate to ask for assistance from your local infectious disease specialists. Their primary mission is the optimal management of complicated, difficult, and complex infections. 

Enhancing Healthcare Team Outcomes

The management of complex UTIs is best performed by an interprofessional team that includes a urologist, nephrologist, infectious disease expert, internist, pharmacist, and primary care provider.Complicated UTIs need to be treated more carefully to serve patients with these infections and to avoid overuse and misuse of antibiotics that will ultimately result in more resistant infections in the future. Using the right antibiotic for the right duration is key. Practitioners should not hesitate to take advantage of infectious disease specialty services in these situations to help optimize antibiotic use. 

Failure of a standard UTI or pyelonephritis to respond to initial treatment should suggest other medical problems such as diabetes, sepsis, an abscess, urinary retention, or an obstructing stone with a possible pyonephrosis. Bladder drainage with a Foley and appropriate imaging tests can identify these problems.

These patients need close monitoring because of potential complications. The outlook for patients with severe UTIs is guarded, and even those who do recover tend to have a prolonged recovery period.[66][184][185] [Level 5]


Article Details

Article Author

Ayan Sabih

Article Editor:

Stephen W. Leslie

Updated:

5/27/2022 2:42:36 PM

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