E v aluatio n an d M an age m e nt

o f U r i n a r y Tr a c t I n f e c t i o n i n
t h e Em e r g e n c y D e p a r t m e n t
Sarah B. Dubbs, MD*, Sarah K. Sommerkamp, MD, RDMS

KEYWORDS
 Urinary tract infection  Asymptomatic bacteriuria  Cystitis  Pyelonephritis
 Renal abscess  Catheter-associated urinary tract infection

KEY POINTS
 Uncomplicated cystitis, a common infection in nonpregnant women, is frequently treated
with an oral antibiotic such as nitrofurantoin.
 Pyelonephritis is an infection of the upper urinary tract. Antibiotic coverage must penetrate
the renal parenchyma. Patients can be treated with fluoroquinolones with or without an
additional dose of intravenous cephalosporin or aminoglycoside.
 Severe infections of the urinary tract include renal and perirenal abscess and emphyse-
matous pyelonephritis. Treatment begins with intravenous antibiotics and general resus-
citation measures, but patients might require percutaneous drainage or even
nephrectomy.
 Antibiotic choice should consider bacterial susceptibilities and, when unavailable, local
antibiograms.
 Special populations (pregnant women, geriatric and pediatric patients, patients with spinal
cord injuries, and renal transplant patients) are more complicated and require increased
attentiveness in their emergency department evaluation.

INTRODUCTION

Genitourinary infections are common among emergency department patients and

stem from a large spectrum of pathologic sources, causing conditions ranging from
the relatively benign and easily treatable to those that threaten fertility and life.

Disclosure Statement: The authors have no relationship with a commercial company that has a
direct financial interest in subject matter or materials discussed in this article or with a company
making a competing product.
Department of Emergency Medicine, University of Maryland School of Medicine, 110 South
Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA
* Corresponding author.
E-mail address: [email protected]

Emerg Med Clin N Am - (2019) -–-

https://doi.org/10.1016/j.emc.2019.07.007 emed.theclinics.com
0733-8627/19/ª 2019 Elsevier Inc. All rights reserved.
2 Dubbs & Sommerkamp

Many of these topics are the focus of other articles in this issue, but this article focuses
on the urinary tract. It is important to note that symptoms can overlap, so the astute
clinician must consider other diagnoses. Urinary tract infections (UTIs) account for
about 8 million visits in outpatient settings, at a cost of $1.5 billion each year.1,2
UTIs occur most frequently in women. They tend to be uncomplicated and can be
treated with oral antibiotics; however, they can progress to involve the upper tract,
leading to sepsis and other complications. When they occur in men and in special
populations, treatment becomes more complex. Antibiotic resistance also compli-
cates treatment strategies.

DEFINITIONS

The term urinary tract infection refers to an inflammatory response of the urothelium
to pathogenic microorganisms within the urinary tract. Pyuria is the presence of
white blood cells (WBCs) in the urine, indicating an inflammatory response. Bacte-
riuria is the presence of bacteria in the urine, traditionally defined as at least 105 cfu/
mL on culture, but a positive result on dipstick is also widely accepted as function-
ally equivalent.
Anatomically, UTIs can be divided into lower and upper tract infections. Lower
tract infections involve the bladder (cystitis) and urethra (urethritis). An upper tract
infection involves the renal parenchyma and collecting system and is referred to as
pyelonephritis. UTIs can be further categorized as simple or complicated. Simple
UTIs, also referred to as uncomplicated UTIs, occur in young, healthy, nonpregnant
women with normal anatomy.3 Complicated UTIs are associated with involvement
of the upper urinary tract; male anatomy; pregnancy; anatomic abnormalities; uro-
lithiasis; the presence of catheters, stents, or tubes; malignancy, chemotherapy,
and immunosuppression; failure of antibiotics; and hospital or health care exposure
(Box 1).4 They can be caused by drug-resistant organisms and are more likely to
require long antibiotic courses or parenteral antibiotics. Asymptomatic bacteriuria
occurs in a patient with no symptoms of UTI but significant bacteria cultured
from the urine.

Box 1
Definition of complicated urinary tract infection

Male
Pregnancy
Urolithiasis
Structural abnormalities of the genitourinary tract (vesicoureteral reflux, stricture, neurogenic
bladder)
Catheters or stents
Failure of antibiotics outpatient
Hospital-associated UTI
Immunocompromised
Malignancy

From Long B, Koyfman A. The emergency department diagnosis and treatment of UTI. Emerg
Med Clin North Am 2018;36:685-710.
 Evaluation and Management of Urinary Tract Infection 3

PATHOPHYSIOLOGY

In the nondiseased state, urine is sterile along the urinary tract, from the renal glomer-
ulus to the external sphincter in males and to the bladder neck in females.5 The main
mechanism by which the tract maintains sterility is the constant unobstructed forward
flow of urine, essentially flushing the system. Other mechanisms that have a significant
role in preventing UTI include urine acidity, immunologic defenses, and mucosal
barriers.6
Abnormalities in the anatomy, structure, or function of the urinary tract disrupt this
flow, leading to a compromise in sterility and possibly to infection. One of the most
common anatomic abnormalities predisposing patients to UTI is incompetence of
the ureterovesical valve, which causes vesicoureteral reflux (VUR). VUR is present in
approximately one-third of children younger than 24 months who present with febrile
UTI.7 VUR can also occur in patients with neurogenic bladder caused by spinal cord
injuries and in patients who have undergone urologic surgery. Other anatomic abnor-
malities, including congenitally acquired urethral valves and bladder diverticulum, can
predispose patients to UTI.
Structural abnormalities can impede urine flow from inside or outside the urinary
tract. Calculi within the urinary tract, associated with UTI, carry significant
morbidity and mortality.8 Masses or tumors originating from the structures of the
urinary tract itself or extrinsic to the tract (such as from the gastrointestinal tract
or gynecologic structures) can obstruct urinary flow. For men, prostatic hypertro-
phy is a common cause of obstruction, as is urethral stricture. In women, fibroids,
a large pregnant uterus, or, later in life, uterine prolapse or cystocele, can obstruct
urinary flow.
Dysfunction in bladder emptying contributes to urinary stasis and infection. Neuro-
genic bladder caused by spinal cord injury is a prime example. Urinary retention can
also be caused by a host of pharmacologic agents, including anticholinergics, antihis-
tamines, antipsychotics, antidepressants, antiparkinsonian agents, sympathomi-
metics, and muscle relaxers.9
Finally, another risk factor for UTI is instrumentation anywhere along the system.
Urethral catheterization is most common and has been recognized for decades as
the single most important predisposing factor in nosocomial UTIs.10 Cystoscopy or
transurethral surgery of any kind, especially involving placement of stents or lysis of
calculi, also puts patients at higher risk for UTI.
When urinary flow is reduced or when the urinary tract undergoes instrumentation,
bacteria that colonize the area around the urethral opening can enter the collection
system and ascend, causing infection. In male patients, the normal flora at the distal
end of the urethra includes staphylococci, streptococci, and diphtheroid organisms. In
female patients, the urethra opens into the perineum, which is colonized by Escheri-
chia coli and other colonic organisms. The female urethra is short, making it easy
for pathogens to ascend to the bladder.
Rarely, UTIs occur via hematogenous or lymphatic spread from adjacent infections,
but these routes do not play a significant role in the most UTIs (Fig. 1).
The most common causative organism for UTI is E coli, which is responsible for
more than 80% of acute community-acquired uncomplicated infections, followed by
Staphylococcus saprophyticus, accounting for 10% to 15% of UTIs.11 Other common
community-acquired urinary pathogens include Proteus, Klebsiella, and Escherichia
faecalis. Nosocomial urinary tract infections are commonly caused by E coli, Klebsi-
ella, Enterobacter, Citrobacter, Serratia, Pseudomonas, E faecalis, Staphylococcus,
and Candida.12
4 Dubbs & Sommerkamp

Fig. 1. Pathophysiology of UTI. Anatomic and structural abnormalities, functional abnor-

malities, and instrumentation or foreign bodies contribute to urinary stasis, allowing bacte-
ria to ascend through the urethra to cause infection of the urinary tract. Rarely, UTI can be
caused by hematogenous or lymphatic spread of bacteria.

CLINICAL FEATURES

A quality history and physical examination are crucial for detecting and differentiating
UTIs as well as complications and life-threatening mimics.

Symptoms and Signs

Cystitis typically presents with dysuria, increased urinary frequency, odor, and supra-
pubic pain. Additional symptoms of fever, vomiting, and flank or back pain developing
a few days after the start of the symptoms suggest pyelonephritis. As the severity of
the infection progresses, the patient might experience dizziness, hypotension, and
altered mental status. A thorough history will help to distinguish a UTI from its mimics
(Box 2).4

Physical Examination
A genital examination should be completed most patients to allow identification of
groin/genital processes that can present with similar symptoms, such as vulvovaginal
candidiasis, sexually transmitted infections (STIs), torsion, and even Fournier
gangrene. Tenderness to percussion at the costovertebral angle (CVA) is commonly
used as an indication of pyelonephritis. Patients with renal or perinephric abscess
may also display CVA tenderness on examination. UTI is a frequent cause of sepsis.
The astute clinician should monitor vital signs and be observant for systemic inflam-
matory response syndrome (SIRS) criteria.

DIAGNOSIS
Laboratory Analysis
After the history and physical examination, laboratory testing is the third pillar in diag-
nosing UTI. A presumptive diagnosis is made by urinalysis and can be confirmed by
urine culture. It is important to note that false-negative urinalysis and culture are
possible, especially in early infection or when the quantity of bacteria or WBCs is low
 Evaluation and Management of Urinary Tract Infection 5

Box 2
Common and life-threatening mimics of urinary tract infection

Bacterial vaginosis
Sexually transmitted disease/cervicitis/urethritis
Pelvic inflammatory disease and tubo-ovarian abscess
Epididymitis/orchitis
Testicular torsion/ovarian torsion
Ectopic pregnancy
Necrotizing soft tissue infection
Cholecystitis
Urolithiasis
Renal abscess, infarction, or thromboembolism
Appendicitis
Sepsis/pneumonia
Abdominal aortic aneurysm

Data from Long B, Koyfman A. The emergency department diagnosis and treatment of UTI.
Emerg Med Clin North Am 2018;36:685-710.

or diluted. False-positive urinalysis and cultures can occur as well. Diagnostic uncer-
tainty is caused by contamination of the specimen during collection. The presence of
epithelial cells on analysis suggests a contaminated sample. The clean catch method
for obtaining voided specimens is the most common method of sample collection. It in-
volves cleaning the periurethral area with a sterile wipe and collection of mid-stream
urine with the foreskin retracted in uncircumcised males or the labia fully separated in
females. In patients who are unable to provide a satisfactory voided sample, urethral
catheterization can be established, with either a single intermittent catheter or an in-
dwelling catheter, if indicated. Care must be taken during catheterization, as it is
possible for bacteria to be introduced into the urinary system during the placement pro-
cess. Suprapubic aspiration is invasive and painful and thus is used infrequently. It is
generally reserved for patients with urinary retention and inability to pass a catheter
through the urethra. It is the catheterization method least likely to cause sample
contamination, yielding the most accurate urinalysis and culture results.13
Urine dipstick testing is the most common initial step in urine laboratory testing. It
can be used in combination with microscopic urine evaluation. The dipstick uses color
change to indicate the presence of leukocyte esterase, nitrite, urobilinogen, protein,
blood, ketones, bilirubin, and glucose and indicates a range of pH and specific gravity.
In case of suspected UTI, the most useful dipstick results are leukocyte esterase and
nitrite. Leukocyte esterase is a marker for WBCs in the urine; however, it does not
exclude WBCs from a vaginal source, for example, Therefore, results might be falsely
positive. The sensitivity of leukocyte esterase alone for UTI is between 59% and 96%.
These results can also be altered by a high glucose or protein concentration, the use of
glucocorticoids, and viral illness. Nitrite positivity is highly sensitive at 95% to 98%.14
A major limitation of its use is its higher false-negative rate. False-negative results
occur when the UTI is caused by non-nitrate-reducing organisms (S saprophyticus,
Pseudomonas, or enterococci). The most specific finding is a specimen that is,
6 Dubbs & Sommerkamp

positive for both leukocyte esterase and nitrite: the specificity improves to 98% to
100%, but the sensitivity declines to 35% to 84%.14
Microscopic evaluation should follow positive results of a urine dipstick and involves
direct visualization under a microscope to count red and WBCs, bacteria, and epithe-
lial cells. This type of evaluation helps the provider determine if the specimen is
contaminated with epithelial cells (ie, was poorly collected). It also provides informa-
tion about the relative number of WBCs. Hematuria and pyuria are often indicators of
an inflammatory response, but bleeding from other causes (eg, vaginal bleeding or
bleeding from bladder or renal masses) may cause red blood cells and WBCs to
show up in the urine also. The absolute number of white cells seen in a sample with
limited epithelial cells is helpful in the diagnosis of UTI. Typically, a count higher
than 10 leukocytes/mm3 correlates with bacterial concentrations of 105 cfu/mL, high
enough to meet the definition of UTI on culture.14
Urine culture is not routinely requested for patients with simple UTI, and culture re-
sults are rarely available in real time to influence therapeutic decisions for a new UTI.
Diagnostic and treatment decisions are made based on the presence of clinical symp-
toms plus a urine dip with or without microscopic evaluation. There is, however, a
place for urine culture in the emergency department. In patients who are ill appearing
or have a complex UTI, culture data are critical for narrowing the antibiotic regimen.
The definition of positive urine culture depends on the route of collection and the pres-
ence of symptoms. A suprapubic specimen should be considered positive with essen-
tially any bacteria present. A catheterized specimen may be considered positive as
low as 102 cfu/mL if a single uropathogen is identified, and the patient has clear symp-
toms. The generally accepted definition of a positive culture in noncatheterized sam-
ples is 105 cfu/mL, although data support a threshold of 102 cfu/mL of a known
uropathogen in patients who have dysuria and frequency.15

Diagnostic Imaging
Diagnostic imaging for UTI in adults is usually not necessary, unless there is concern
about an alternative diagnosis such as the mimics discussed previously or a compli-
cation. Radiographs have the benefit of minimizing the patient’s radiation exposure
compared with other modalities, but they have low sensitivity for the abnormalities
of the genitourinary system. In contrast, computed tomography (CT) is frequently
used for evaluation of patients with a complicated UTI. It can show renal stones
with or without associated hydroureter and hydronephrosis, abscess, vascular issues
and other surgical mimics, necrotizing infections, abdominal aortic aneurysm, chole-
cystitis, or appendicitis. CT use should be limited because of the radiation exposure.
Ultrasound is another diagnostic option, and it is ideal because it does not involve ra-
diation. It is the test of choice for identifying pelvic pathology, pregnancy, torsion, and
tubo-ovarian abscess (TOA). Ultrasound provides visualization of the kidneys and pa-
thology such as hydronephrosis, abscess, and edema/stranding.

MANAGEMENT
Asymptomatic Bacteriuria
In asymptomatic bacteriuria, the patient has bacteria in the urine but no symptoms
of UTI. The quantitative definition of asymptomatic bacteriuria requires a clean,
midstream catch with culture results showing a quantitative count of at least
105 cfu/mL of a single bacterial species (in a single specimen for male patients
or 2 consecutive specimens yielding the same species for female patients) or a
catheterized specimen with at least 102 cfu/mL.16,17 Of course, emergency
 Evaluation and Management of Urinary Tract Infection 7

medicine physicians do not routinely request urine cultures for asymptomatic pa-
tients. Patients may have had a culture obtained previously. However, frequently
the results are not known during an index visit to the emergency department.
The emergency physician must entertain the diagnosis of asymptomatic bacteriuria
when bacteria are visualized on the microscopic portion of urinalysis. Nonpregnant
patients with asymptomatic bacteriuria are typically not treated, because they often
clear the bacteria without antimicrobials.18 Pregnant women, however, are treated
for 3 to 7 days to decrease the risk of preterm birth, low-weight birth, and progres-
sion to pyelonephritis.17

General Principles of Antimicrobial Management

The goal of treatment is to eliminate the pathogen from the urine, so antimicrobial
agents are key. Two main factors are important in antimicrobial selection. First, the
pathogen must be susceptible to the antimicrobial, and, second, the antimicrobial
must become concentrated in the urine at a level high enough to be effective against
that pathogen (above the minimal inhibitory concentration [MIC]). Fortunately, the level
of many antibiotics in the urine is often hundreds of times higher than in the serum, so
an inhibitory level can be achieved with oral dosing of many commonly used antimi-
crobial agents (except macrolides).13 Therefore, the serum concentration of the anti-
microbial is not important in cases of simple, uncomplicated cystitis. In contrast, it is
critical for patients with complicating factors such as bacteremia, fever, or infections
involving the renal or prostatic parenchyma. In patients with renal insufficiency,
whether acute or chronic, dosage adjustments may be required for antimicrobials
that are cleared primarily by the kidneys. Patients with end-stage renal failure cannot
concentrate antimicrobials effectively in the urine, so eradication of urine pathogens is
challenging. Finally, because urinary tract obstruction can affect antimicrobial concen-
tration in the urine, the obstruction should always be addressed as early as possible.
Antibiotic resistance has led to difficulty in treating common illnesses such as UTIs,
which is a concern for the individual being treated and for the public. The US Centers
for Disease Control and Prevention (CDC) and other major organizations strongly
recommend improving antibiotic stewardship.19 The emergency physician is in a diffi-
cult position when treating bacterial infections. Urine culture results are rarely available
during the emergency department evaluation, so antibiotics must be started empiri-
cally. The ideal situation is treatment that is individually tailored to the sensitivity of
the pathogen that is present. When urine culture results are available, they should
be used to guide treatment. When culture results are not available, the hospital anti-
biogram should be used to determine resistance patterns and guide antibiotic selec-
tion. There is not a standardized method of collecting information for an antibiogram,
so it may be prudent to become familiar with the local antibiogram, specifically ascer-
taining if it includes inpatient, outpatient, and intensive care unit specimens or if it rep-
resents only outpatient or emergency department patients, who tend to have greater
sensitivity to antibiotics.20

Uncomplicated Cystitis
The most common presentation of UTI is uncomplicated cystitis. It occurs in premen-
opausal, nonpregnant women who have no other anatomic genitourinary tract abnor-
malities. Approximately 50% of women experience uncomplicated UTI in their
lifetime.19 By definition, uncomplicated cystitis is a superficial infection of the bladder
mucosa; therefore, systemic symptoms such as fever, chills, and vomiting should not
be present. Patients might have suprapubic tenderness but should otherwise have an
unremarkable examination.
8 Dubbs & Sommerkamp

Most uncomplicated cystitis cases are caused by E coli. The second most common
cause is S saprophyticus, and the remaining but less common causes are Klebsiella,
Proteus, and Enterococcus.11
As discussed previously, in a symptomatic patient, urinalysis showing micro-
scopic bacteriuria and pyuria, with or without hematuria, is sufficient to make a
presumptive diagnosis of UTI. Dipstick tests for bacteria (as indicated by the pres-
ence of nitrite) and WBCs (as indicated by the presence of leukocyte esterase) are
more cost- and time-efficient, but they are slightly less sensitive than microscopic
urine evaluation. Urine culture is not necessary in most cases of uncomplicated
cystitis.
Oral antimicrobials are preferred in the treatment of uncomplicated cystitis. Nitrofur-
antoin is effective, well tolerated, and relatively inexpensive. Trimethoprim (TMP) and
trimethoprim-sulfamethoxazole (TMP-SMX) are also well tolerated, require a short
course of only 3 days, and are inexpensive. These agents are recommended as
first-line therapy, as long as local E coli resistance rates are less than 20%.21 Fluoro-
quinolones such as ciprofloxacin and levofloxacin are falling out of favor because of
the increasing resistance to them as well as their adverse side-effect profiles. They
are now used only as second-line alternatives in the treatment of uncomplicated
cystitis. Fosfomycin trometamol, given in a single 3 g oral dose, is much more expen-
sive that the aforementioned agents, but it might provide a cost savings in some sit-
uations if lack of compliance with a multiday regimen would cause recidivism due
to worsening illness. Pivmecillinam is an oral antimicrobial that is available in parts
of Europe, but not yet in the United States. It is an extended-spectrum penicillin
with good activity against bacteria with extended-spectrum beta-lactamase (ESBL)
activity and has minimal effect on intestinal and vaginal flora,22 potentially decreasing
rates of selection for antibiotic-resistant organisms. Despite their advantages, fosfo-
mycin and pivmecillinam have decreased efficacy compared with nitrofurantoin,
TMP, TMP-SMX, and fluoroquinolones.21 Other alternative antibiotic regimens for un-
complicated UTI are penicillins and cephalosporins. Antibiotic regimens for uncompli-
cated cystitis are summarized in Box 3.
Patients with uncomplicated cystitis do not require admission to the hospital. They
can be discharged home on an oral antibiotic regimen.

Pyelonephritis
Pyelonephritis is a bacterial infection of the kidney parenchyma. Most cases occur by
ascension of bacteria through the urinary tract, beginning as cystitis. Few cases are
caused by hematogenous spread and are associated with virulent organisms such
as S aureus, P aeruginosa, Salmonella, and Candida.23 Patients with acute pyelone-
phritis classically present with fever, flank pain, and vomiting associated with tender-
ness at the costovertebral angle and laboratory diagnosis of urinary infection. It is
important to note that the urine sample might not show signs of inflammation or infec-
tion if the ureter draining the infected kidney is obstructed or if the kidney infection is
outside the collecting system.
The Infectious Diseases Society of America (IDSA) recommends that urine
cultures with susceptibility testing be obtained for all patients with acute pyelone-
phritis.21 Blood cultures should be requested for patients who appear severely ill.
Up to 25% of female patients with acute uncomplicated pyelonephritis have posi-
tive blood cultures,24 but it is rare for the results of these cultures to alter manage-
ment. Diagnostic imaging should be considered, especially if there is concern for
stone or other obstruction, abscess, emphysematous pyelonephritis, mass, or other
UTI mimics.
 Evaluation and Management of Urinary Tract Infection 9

Box 3
Empiric antibiotic regimens for uncomplicated urinary tract infection
Nitrofurantoin 100 mg Twice daily 5d First line, well-tolerated,
monohydrate inexpensive.
TMP-SMX 160 mg/800 mg Twice daily 3d First line if E coli resistance
<20%, well-tolerated,
inexpensive
Fluoroquinolones Second line: falling out of
Ciprofloxacin 500 mg Twice daily 7d favor because of
Levofloxacin 750 mg Once daily 5d increasing resistance and
adverse side-effect
profiles
Fosfomycin trometamol 3 g Once More expensive, slightly
lower efficacy than first-
line agents, but may
prevent recidivism
Amoxicillin-clavulanate 500 mg/125 mg Twice daily 3–7 d Alternative treatment
when other agents
cannot be used, lower
efficacy
Cephalosporins Alternative treatment
Cefdinir 300 mg Twice daily 7d when other agents
Cefaclor 500 mg 3 times daily 7d cannot be used, lower
Cefpodoxime 100 mg Twice daily 7d efficacy
Cefuroxime 250 mg Twice daily 7–10 d
Pivmecillinam 400 mg Twice daily 4–7 d Availability limited to only
some European countries

For patients with acute pyelonephritis not complicated by abscess, calculi, or

other factors, the mainstay of treatment is antibiotics and supportive care.
Antipyretics and antiemetics are helpful to control symptoms. Intravenous fluids
may be administered if the patient is dehydrated as a result of vomiting or poor
oral intake.
Antimicrobials initiated in the emergency department should include coverage
against E coli, which accounts for the majority of cases. Coverage against more viru-
lent or resistant organisms should be considered in patients with recurrent UTIs,
indwelling urinary catheters, or a history of instrumentation. If vomiting is controlled,
and the concern for bacteremia is low, outpatient treatment with oral medications is
appropriate. In areas where uropathogen resistance to fluoroquinolones is less than
10%, ciprofloxacin or levofloxacin is recommended. It is common for patients to
receive an intravenous dose of ceftriaxone or aminoglycoside during their emergency
department stay, even if they are being discharged with a prescription for an oral flu-
oroquinolone. In areas where local uropathogen resistance to fluoroquinolones ex-
ceeds 10%, this parenteral regimen is actually recommended by the IDSA, to be
administered in the emergency department before the patient is discharged on the flu-
oroquinolone. The same single-dose parenteral antibiotic regimen is recommended if
TMP-SMX or beta-lactams, both second-line agents, are chosen for empiric treat-
ment. Oral beta-lactams such as cefpodoxime are considered second-line treatment
for pyelonephritis, because, even when the cultured pathogen is susceptible, treat-
ment failure rates are high. Fosfomycin and nitrofurantoin, although effective for
cystitis, are not effective for pyelonephritis, because they are mainly concentrated in
the bladder.21,25,26 Treatment choices, dosing, and duration of treatment are summa-
rized in Box 3.
10 Dubbs & Sommerkamp

Indications for admission and inpatient management of patients with acute pyelone-
phritis include uncontrolled vomiting, signs of SIRS/sepsis, pregnancy, male anatomy,
renal transplant, and other complicating factors such as the presence of calculi,
ureteral stents/drains, and indwelling catheters. These patients should be initiated
on intravenous antibiotics. Regimens may include fluoroquinolones, aminoglycoside
with or without ampicillin, extended-spectrum cephalosporin or extended-spectrum
penicillin with or without aminoglycoside, or a carbapenem. The treatment choice
should be based on local resistance patterns.21 Choices, dosing, and duration for
inpatient treatment of pyelonephritis are summarized in Box 4.

Emphysematous Pyelonephritis
Emphysematous pyelonephritis is a urologic emergency. Gas-forming pathogens
cause a severe necrotizing infection of the renal parenchyma and perirenal space.
This infection typically occurs in diabetic patients, and it is hypothesized that the
high glucose levels in their tissues provide a substrate and favorable environment
for E coli, which ferments the sugar and produces carbon dioxide. Many patients
with emphysematous pyelonephritis have significant renal dysfunction or urinary
obstruction from calculi or papillary necrosis. This urologic emergency carries a
high mortality rate, ranging from 19% to 43%.27,28
Patients with emphysematous pyelonephritis are at the severe end of the clinical py-
elonephritis spectrum. Diagnosis is confirmed with imaging, typically CT scan of the
abdomen and pelvis.

Box 4
Empiric antibiotic regimens for pyelonephritis
Outpatient Empiric Treatment
Ciprofloxacina 500 mg Oral Twice daily 7d
Levofloxacina 750 mg Oral Once daily 5–7 d
Cefpodoxime 200 mg Oral Twice daily 10–14 d
TMP-SMX 160–800 mg Oral Twice daily 10–14 d
(double-
strength)
Ceftriaxone 1g Intramuscularly or Once
intravenously
Gentamycin 5 mg/kg Intramuscularly or Once
intravenously
Ciprofloxacin 400 mg Intravenously Once
Inpatient Empiric Treatment
Ciprofloxacin 400 mg Intravenously Every 12 h
Levofloxacin 500 mg Intravenously Every 24 h
Ceftriaxone 1g Intravenously Every 24 h 1/ aminoglycoside
(eg, gentamicin)
Gentamicin 5 mg/kg Intravenously Every 24 h 1/ ampicillin 2 g
intravenously every
4 hours
Tobramycin 5 mg/kg Intravenously Every 24 h 1/ ampicillin 2 g
intravenously every
4 hours
Piparacillin/ 3.375 g Intravenously Every 6 h 1/ aminoglycoside
tazobactam (eg, gentamicin)
Meropenem 2g Intravenously Every 8 h
a
Consider initial dose of parenteral agent if fluoroquinolone resistance is >10%, or if using
second-line agent (beta-lactam such as cefpodoxime or TMP-SMX).
 Evaluation and Management of Urinary Tract Infection 11

Prompt urology consultation, administration of intravenous broad-spectrum antibi-

otics, and fluid resuscitation are the keys in emergency department management of
these patients. If urinary obstruction is present, percutaneous catheter drainage must
be done as soon as possible, usually by an interventional radiologist. In the past, definitive
treatment involved nephrectomy after resuscitation and stabilization; however, modern
treatment tends toward a more conservative approach of percutaneous drainage and
medical management with antibiotics.29 In severe cases, nephrectomy may be required.

Renal Abscess and Perinephric Abscess

Renal abscesses are purulent infectious collections confined to the renal parenchyma.
They occur most often in patients with renal disease or urinary obstruction and are
typically caused by gram-negative organisms. Perinephric abscess results either
from rupture of a cortical abscess into the perinephric space, or, less frequently, he-
matogenous seeding from other sites of infection. Renal abscess and perinephric ab-
scess should be suspected in patients who are not improving after receiving
appropriate antimicrobial therapy for pyelonephritis. CT is the imaging modality of
choice, although larger abscesses can be visualized on ultrasound. The major advan-
tage to CT is the ability to visualize calculi and other causes of obstruction that could
have contributed to development of the abscess.
Classically, treatment of renal abscess calls for open or percutaneous drainage, but
there is evidence supporting noninvasive treatment with antibiotics and observation
for small abscesses (3 to 5 cm) in hemodynamically stable patients.30–33 Antibiotic
choice, as with pyelonephritis, should be directed toward gram-negative organisms,
guided by local resistance patterns. Staphylococcus coverage may be considered if
hematogenous dissemination is suspected (ie, endocarditis, skin abscess or cellulitis,
or in-dwelling lines).
Small perinephric abscesses (<3 cm) can be treated nonsurgically as well.34,35 Peri-
nephric abscesses larger than 3 cm should be drained percutaneously or surgically as
early as possible for infectious source control. Some patients will eventually require
nephrectomy.

Urolithiasis
The relationship between urolithiasis and infection is complex. Traditionally, it was
thought that the stones were a consequence of the infection. Certain bacteria,
such as urease-producing Proteus, promote an environment for crystals to precipi-
tate and form calculi. The relationship is now known to be more complex, with
some infections occurring as a consequence of obstruction from the stone.8,36,37
Whatever its origin, UTI in the setting of urolithiasis is a complex condition that war-
rants careful management and urologic consultation. Urinalysis results should be
given special attention in patients presenting with suspected urolithiasis, looking
beyond hematuria for signs of infection. Abrahamian and colleagues38 found that a
WBC count greater than 5/hpf was 86% sensitive and 79% specific for UTI
confirmed by culture in the setting of nephrolithiasis. WBC count greater than 20/
hpf was even more specific for UTI, at 93%. Patients in this case series were
more likely to be female and to present with fever, chills, dysuria, and urinary fre-
quency.38 Antimicrobials should be initiated promptly. If hydronephrosis or an
obstructive stone is present, intervention is necessary to mitigate worsening or
life-threatening illness. Patients with UTI and a nonobstructing stone may be treated
in the outpatient setting, given the availability of close outpatient follow-up with
urology.38
12 Dubbs & Sommerkamp

Acute Bacterial Prostatitis

Acute bacterial prostatitis presents with constitutional symptoms of fever, chills, and
malaise, as well as dysuria or other urinary symptoms and perineal or rectal pain. It is
commonly associated with urinary retention, or it can occur after instrumentation such
as cystoscopy or prostate biopsy. A digital prostate examination can reveal exquisite
prostate tenderness. This manipulation of the prostate should be avoided in febrile,
neutropenic, or ill-appearing patients. Imaging of the prostate is generally not neces-
sary for the diagnosis but should be obtained if abscess or an alternative diagnosis in
the differential is suspected. Treatment includes antibiotics and relief of urinary
obstruction, if present, with a drainage catheter and/or alpha-blockers. Prostate ab-
scess requires drainage, because medical management is often unsuccessful.39,40

Catheter-Associated Urinary Tract Infection

Catheter-associated UTIs (CAUTIs) are the fourth most common health care-associated
infection.41,42 Bacteriuria has an incidence of 10% per day of indwelling catheterization.
For intermittent catheterization, bacteriuria occurs at a rate of 1% to 3% each time a
patient is catheterized. The urinary catheter system provides an environment that pro-
motes the growth of bacterial biofilms. Pseudomonas and Proteus are especially
amenable to this environment, and, in addition to E coli and Enterococcus, contribute
to a large percentage of CAUTIs. Most patients with bacteriuria are asymptomatic,43
but those with active infection can present with fever, suprapubic tenderness, CVA
tenderness, altered mental status, or hypotension. Therefore, only symptomatic
catheter-associated bacteriuria should be treated. Criteria for CAUTI vary across the
IDSA, CDC, and other guiding organizations and are heavily based on culture results,
which is not helpful in the emergency department. However, studies have suggested
that certain urinalysis findings indicate CAUTI, which is more helpful when making an
empiric diagnosis in the emergency department. The presence of pyuria and a WBC
count greater than 5/hpf has been found to have 90% specificity based on cultures
with greater than 105 cfu/mL.44 Another study found the presence of leukocyte
esterase to have a sensitivity of 87.5% and the presence of nitrite to be 100% specific
in CAUTI.45 When CAUTI is suspected, urine cultures should be requested, and
antibiotics should be started promptly. The catheter should be replaced or removed,
as it is likely to be colonized with the offending microorganism, and encrustation of
the biofilm can shelter the bacteria from exposure to the antimicrobial medication.

URINARY TRACT INFECTIONS IN SPECIAL POPULATIONS

Asymptomatic Bacteriuria and Urinary Tract Infection During Pregnancy
Bacteriuria in pregnant women, even when asymptomatic, has been associated with
complications such as maternal sepsis, premature birth, and low birth weight and
therefore should always be treated with antimicrobials. Pyelonephritis develops in
up to 30% of pregnant women with untreated bacteriuria.46,47 Aminopenicillins and
cephalosporins are considered safe and generally effective in pregnant patients
with asymptomatic bacteriuria. Nitrofurantoin is effective but should be avoided in pa-
tients with G6PD, as well as in the first trimester of pregnancy, because of possible
linkage to birth defects. It is otherwise approved by the American College of Obstetrics
and Gynecology (ACOG) for use in pregnant women in the second and third trimesters,
given that they do not have G6PD. Nitrofurantoin may be used in the first trimester if no
other agent is available to treat an infection.48 ACOG notes that penicillins, erythro-
mycin, and cephalosporins have not been found to increase the risk of birth defects
and are therefore preferred agents when appropriate.48
 Evaluation and Management of Urinary Tract Infection 13

Pregnant patients with pyelonephritis are at high risk for maternal and fetal compli-
cations. They require prompt obstetric consultation, parenteral antibiotics, and admis-
sion to the hospital.

Bacteriuria and Urinary Tract Infection in the Elderly

Diagnosis of UTI in the geriatric population is challenging. Traditional UTI symptoms
might be absent or might not be communicated if the history is limited. Concomitant
disease can mask or mimic UTI. Pyuria alone is not a good predictor of urine infection
in the elderly.49 Nitrite positivity in addition to pyuria and bacteriuria suggests active
infection, although it should be understood that not all uropathogenic organisms pro-
duce nitrite. In terms of ruling out UTI, negative results for leukocyte esterase and ni-
trite on dipstick are reliable.50,51 When urinalysis findings are equivocal in an elderly
patient presenting with vague symptoms such as altered mental status or frequent
falls, alternative diagnoses should be sought.
When evidence of a UTI warrants treatment, antibiotic choice should always be
made with extra caution in the elderly population. More complicated UTIs with asso-
ciated complications such as altered mental status and sepsis require parenteral an-
tibiotics. For select patients who may be discharged home, oral antibiotics must also
be chosen carefully. Nitrofurantoin, usually a first-line agent, must be avoided in pa-
tients with renal insufficiency, as decreased renal excretion causes inadequate urine
concentration. This increases the possibility for toxicity, and further decreases the
chance of the antibiotic to be effective, because urine levels are below the minimum
inhibitory concentration. Previous data supported avoidance of nitrofurantoin in pa-
tients with creatinine clearance of less than 60 mL/min, but more recent data support
using the drug in patients with creatinine clearance of 40 mL/min or higher.52

Urinary Tract Infection in Patients with Spinal Cord Injury

UTI is common in patients with spinal cord injury (SCI) and is the most common cause
of fever in this population.53 SCI patients have many characteristics that place them at
high risk for UTI, including impaired bladder emptying, instrumentation/catheteriza-
tion, decreased fluid intake, decubitus ulcers, and reduced host defenses from
chronic illness. Patients with SCI usually do not experience the classic UTI symptoms
of dysuria, frequency, or urgency because of their loss of sensation. They more often
present with vague abdominal discomfort, spasticity, fatigue, fever, or cloudy or
malodorous urine. Only 20% of UTIs in SCI patients are caused by E coli. Enterococci,
P mirabilis, and Pseudomonas are more common in this patient population. Addition-
ally, SCI patients are more likely to have polymicrobial UTIs.54–56 They also demon-
strate a high rate of antimicrobial resistance.57 Typical antibiotic regimens for UTI in
SCI patients include aminoglycoside plus a penicillin or a third-generation cephalo-
sporin; however, previous culture data must be considered to screen for a history of
resistant organisms.

Other Special Populations

Evaluation and management of UTI in the pediatric as well as renal transplant popu-
lations are complex as well. These topics are discussed in their respective sections
of this edition of Emergency Medicine Clinics.

SUMMARY

UTI affects patients of all ages and is a diagnosis that an emergency physician might
make multiple times per shift. The range of presentations and severity span the gamut
14 Dubbs & Sommerkamp

of routine run-of-the-mill to roller-coaster resuscitation. It is essential for emergency

physicians to combine a thorough history, physical examination, and selective diag-
nostic testing for accurate diagnosis. Fluency in the interpretation of urine tests is
imperative. Appropriate antibiotic selection requires emergency physicians to be
knowledgeable about the resistance patterns of uropathogens in their own hospitals
and emergency departments. Special populations require adjustments in diagnosis,
treatment, and antibiotic choice. A deep understanding of this subject is guaranteed
to be practical and valuable in the daily clinical decision making of any emergency
physician’s practice.

ACKNOWLEDGMENTS

The authors would like to thank Linda J. Kesselring, MS, ELS, for copy editing this
article.

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