para>Bacteriuria is common among the elderly; may be related to functional status and usually is transient. Of men older than 65 years of age, 5 " “10% have asymptomatic bacteriuria (ASB). If ASB is noted, no treatment is needed (6,7). ‚
Pediatric Considerations
Can be associated with obstruction to normal flow of urine, such as vesicoureteral reflux. Unique diagnostic criteria and evaluation recommendations exist (see below) (8).
‚
DIAGNOSIS
HISTORY
- Urinary frequency
- Urinary urgency
- Dysuria
- Hesitancy
- Slow urinary stream
- Dribbling of urine
- Nocturia
- Suprapubic discomfort or perineal pain
- Low back pain
- Hematuria
- Systemic symptoms (chills, fever) or flank pain, nausea, vomiting present with concomitant pyelonephritis or prostatitis (9).
PHYSICAL EXAM
- Suprapubic tenderness
- Costovertebral angle (CVA) tenderness and/or fever may be present with concomitant pyelonephritis/prostatitis/epididymitis.
DIFFERENTIAL DIAGNOSIS
- Anatomic/functional pathology of the urinary tract
- Urethritis/STIs
- Infections in other sites of the genitourinary tract (e.g., epididymis, prostatitis). More than 90% of men with febrile UTI have concomitant prostate infection (9).
DIAGNOSTIC TESTS & INTERPRETATION
- Urine dipstick/manual microscopy of clean catch midstream void showing the following:
- Pyuria (>10 WBCs)
- Bacteriuria
- Positive leukocyte esterase (in males: sensitivity, 78%; specificity, 59%; positive predictive value [PPV], 71%; negative predictive value [NPV], 67%)
- Positive nitrite (in males: sensitivity, 47%; specificity, 98%; PPV, 96%; NPV, 59%)
- In general, leukocyte esterase is more sensitive and nitrite is more specific in detecting UTI (10).
- Automated microscopy/flow cytometry that measures cell counts and bacterial counts can be used to improve screening characteristics (sensitivity, 92%; specificity, 55%; PPV, 47%; NPV, 97%). The high NPV of these screening tests allows for more judicious use of urine culture (11).
- Urine culture: >100,000 colony-forming units (CFU; >105 CFU) of bacteria/mL of urine confirm diagnosis.
- Lower counts, such as >103 CFU, also may be indicative of infection, especially in the presence of pyuria.
- Diagnosis in infants and children <24 months made on the basis of both pyuria and 50,000 CFU on culture.
- Renal and bladder ultrasound recommended in infants and young children after first confirmed UTI.
Follow-Up Tests & Special Considerations
- Consider assessing for risk factors for STIs, as chlamydial/gonococcal urethritis can mimic a UTI. If risk factors are present, use urine nucleic acid amplification tests to identify gonococcal and Chlamydia infections and treat as necessary.
- Further urologic evaluation is warranted to rule out other disorders in men with recurrent UTI, febrile UTI, or pyelonephritis. This may include the following:
- Ultrasound
- Cystoscopy
- Urodynamics
- IV pyelography
- Value of a urologic evaluation in a single uncomplicated UTI has not been determined (9).
- Antibiotics prior to culture or phenazopyridine prior to urine dipstick can alter results.
Test Interpretation
Depends on site of infection ‚
TREATMENT
GENERAL MEASURES
- Hydration
- Analgesia, if required
- Patient with indwelling catheters
- If asymptomatic bacterial colonization, no need to treat (sterilization of urine is not possible, and resistant organisms may take up residence).
- If symptomatic of acute infection, institute treatment.
MEDICATION
First Line
- Acute, uncomplicated cystitis
- Treat empirically; strongly consider if nitrite positive, using local resistance patterns or based on culture and sensitivity results for 7 days (9)[B]. For empirical therapy, a fluoroquinolone or trimethoprim-sulfamethoxazole DS usually used to treat the most likely pathogens (9).
- Complicated, febrile, or recurrent infection
- Prescribe a minimum of 2 weeks antibiotics based on antimicrobial sensitivities with repeat urine check after the treatment. In men with febrile UTI or pyelonephritis, prostatic involvement also has to be considered. Treatment of concomitant prostatitis requires antimicrobials with good prostatic tissue and fluid penetration (fluoroquinolones) (9)[B].
Second Line
According to culture and sensitivity results and patient 's history ‚
ISSUES FOR REFERRAL
Further urologic evaluation and referral are warranted to rule out other disorders in men with recurrent UTI, febrile UTI, or pyelonephritis. ‚
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
- Inability to tolerate oral medications
- Acute renal failure
- Suspected sepsis
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Patient Monitoring
Close follow-up until clinically well ‚
DIET
Encourage adequate fluid intake. ‚
PATIENT EDUCATION
For patient education materials about this topic that have been reviewed favorably, contact the National Kidney Foundation, 30 E. 33rd Street, Suite 1100, New York, NY 10016; 212-889-2210. ‚
PROGNOSIS
Clearing of infections with appropriate antibiotic treatment ‚
COMPLICATIONS
- Pyelonephritis
- Ascending infection
- Recurrent infection
- Prostatitis
REFERENCES
11 Griebling ‚ TL. Urological Diseases in America project: trends in resource use for urinary tract infections in men. J Urol. 2005;173(4):1288 " “1294.22 Wagenlehner ‚ FM, Weidner ‚ W, Pilatz ‚ A, et al. Urinary tract infections and bacterial prostatitis in men. Curr Opin Infect Dis. 2014;27(1):97 " “101.33 Semins ‚ MJ, Shore ‚ AD, Makary ‚ MA, et al. The impact of obesity on urinary tract infection risk. Urology. 2012;79(2):266 " “269.44 Drekonja ‚ DM, Rector ‚ TS, Cutting ‚ A, et al. Urinary tract infection in male veterans: treatment patterns and outcomes. JAMA Intern Med. 2013;173(1):62 " “68.55 Jepson ‚ RG, Williams ‚ G, Craig ‚ JC. Cranberries for preventing urinary tract infections. Cochrane Database Syst Rev. 2012;(10):CD001321.66 Rowe ‚ TA, Juthani-Mehta ‚ M. Diagnosis and management of urinary tract infection in older adults. Infect Dis Clin North Am. 2014;28(1):75 " “89.77 Matthews ‚ SJ, Lancaster ‚ JW. Urinary tract infections in the elderly population. Am J Geriatr Pharmacother. 2011;9(5):286 " “309.88 Roberts ‚ KB, Downs ‚ SM, Finnell ‚ SM, et al. Urinary tract infection: clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. Pediatrics. 2011;128(3):595 " “610.99 Grabe ‚ M, Bishop ‚ MC, Bjerklund-Johansen ‚ TE, et al. Uncomplicated urinary tract infections in adult. In: Guidelines on Urological Infections. Arnhem, The Netherlands: European Association of Urology; 2013:15 " “25.1010 Koeijers ‚ JJ, Kessels ‚ AG, Nys ‚ S, et al. Evaluation of the nitrite and leukocyte esterase activity tests for the diagnosis of acute symptomatic urinary tract infection in men. Clin Infec Dis. 2007;45(7):894 " “896.1111 Evans ‚ R, Davidson ‚ MM, Sim ‚ LR, et al. Testing by Sysmex UF-100 flow cytometer and with bacterial culture in a diagnostic laboratory: a comparison. J Clin Pathol. 2006;59(6):661 " “662.
ADDITIONAL READING
- Coupat ‚ C, Pradier ‚ C, Degand ‚ N, et al. Selective reporting of antibiotic susceptibility data improves the appropriateness of intended antibiotic prescriptions in urinary tract infections: a case-vignette randomised study. Eur J Clin Microbiol Infect Dis. 2013;32(5):627 " “636.
- Foxman ‚ B. Urinary tract infection syndromes: occurrence, recurrence, bacteriology, risk factors, and disease burden. Infect Dis Clin North Am. 2014;28(1):1 " “13.
- Gerber ‚ GS, Brendler ‚ CB. Evaluation of the urologic patient: history, physical examination, and urinalysis. In: Walsh ‚ PC, Retik ‚ AB, Vaughn ‚ EDJr, et al, eds. Campbell 's Urology. 8th ed. Philadelphia, PA: Saunders; 2002:107.
- Koeijers ‚ JJ, Verbon ‚ A, Kessels ‚ AG, et al. Urinary tract infection in male general practice patients: uropathogens and antibiotic susceptibility. Urology. 2010;76(2):336 " “340.
SEE ALSO
- Prostate Cancer; Prostatic Hyperplasia, Benign (BPH); Prostatitis; Pyelonephritis; Urethritis
- Algorithms: Dysuria; Urethral Discharge
CODES
ICD10
- N39.0 Urinary tract infection, site not specified
- N30.90 Cystitis, unspecified without hematuria
- N30.91 Cystitis, unspecified with hematuria
- N30.00 Acute cystitis without hematuria
- N33 Bladder disorders in diseases classified elsewhere
- N30.81 Other cystitis with hematuria
- N30.21 Other chronic cystitis with hematuria
- N30.20 Other chronic cystitis without hematuria
- N30.01 Acute cystitis with hematuria
- B96.20 Unsp Escherichia coli as the cause of diseases classd elswhr
- N30.80 Other cystitis without hematuria
ICD9
- 599.0 Urinary tract infection, site not specified
- 595.9 Cystitis, unspecified
- 595.0 Acute cystitis
- 595.2 Other chronic cystitis
- 595.4 Cystitis in diseases classified elsewhere
- 595.89 Other specified types of cystitis
SNOMED
- 68566005 urinary tract infectious disease (disorder)
- 38822007 Cystitis (disorder)
- 68226007 Acute cystitis
- 33655002 Chronic cystitis
- 431308006 Acute upper urinary tract infection (disorder)
- 197845000 Cystitis associated with another disorder
- 4009004 Lower urinary tract infectious disease (disorder)
CLINICAL PEARLS
- Cystitis is an infection of the lower urinary tract, usually resulting from a single gram-negative enteric bacteria.
- Risk factors/causes: age, history of UTI, obesity, BPH, cognitive impairment, fecal incontinence, urinary incontinence, anal intercourse, recent urologic surgery, catheterization, infection of the prostate/kidney, urinary tract instrumentation, immunocompromised host, diabetes, neurogenic bladder, outlet obstruction, sex with infected female partner
- Evaluation: urinalysis, urine culture, STI testing (e.g., gonorrhea, Chlamydia by culture/DNA probe)
- Treat empirically with fluoroquinolones or trimethoprim-sulfamethoxazole DS for 7 days.