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StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

Complicated Urinary Tract Infections

Ayan Sabih; Stephen W. Leslie.

Author Information and Affiliations

Last Update: November 12, 2023.

Continuing Education Activity

Urinary tract infections (UTIs) are among hospitals' most common presenting
causes of sepsis. Some simple UTIs can be managed with outpatient antibiotics,
leading to almost universally good outcomes. However, complicated UTIs may
lead to florid urosepsis, which can be fatal. Several risk factors can complicate
UTIs, leading to treatment failure, repeat infections, or significant morbidity and
mortality. It is essential to determine if the patient's infection may have resulted
from one of these risk factors and whether the episode will likely resolve with
first-line antibiotics. Complicated UTIs present with more significant morbidity,
carry a higher risk of treatment failure, and typically require longer antibiotic
courses, frequently requiring additional workup. This activity reviews the
evaluation and management of complicated UTIs and highlights the role of
interprofessional team members in collaborating to provide well-coordinated
care and enhance outcomes for affected patients.

Objectives:

Differentiate between simple and complicated urinary tract infections based

on risk factors, clinical presentation, and potential complications.

Assess patients with complicated urinary tract infections to identify

underlying anatomical abnormalities, immune status, and potential sources
of infection.

Implement evidence-based management protocols for the appropriate use

of antibiotics and treatment strategies tailored to specific risk profiles.

Collaborate amongst the interprofessional team to enhance and ensure

continuity of care for patients affected by complicated urinary tract
infections.

Access free multiple choice questions on this topic.

Introduction

Urinary tract infections (UTIs) are among the most common causes of sepsis
presenting in 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 an almost universally good outcome. 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 leading 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 infections typically require longer courses
of treatment, different antibiotics, and sometimes additional workups.

In a clinical context 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
an incidental positive urine culture in an asymptomatic, afebrile non-pregnant
immune-competent female. A complicated UTI is any UTI other than a simple UTI,
as defined above. Therefore, all UTIs in immunocompromised patients, males,
pregnant patients, 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 UTI 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 immunocompromised state, for example,

steroid use, postchemotherapy, diabetes, HIV, older individuals

Atypical organisms causing UTI

Recurrent infections despite adequate treatment (multi-drug resistant

organisms)

Infections occurring in pregnancy (including asymptomatic bacteriuria)

Infections occurring 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 UTIs 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
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 UTIs, comprising about 1.8% of all annual hospitalizations, with 80%
of these being non-catheter related.[11] Cohorts with more risk factors show an
increased incidence of UTIs. 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 1 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 of bacteriuria progressing to a UTI.

About 20% of all bacteremias associated with health care 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 older 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. Of these, about 22% (220 000) are considered complicated UTIs,
and about 100 000 are admitted to the hospital yearly.[16][17]

Pathophysiology
A biofilm is an encapsulated, structured microorganism colony that has created
its polymeric matrix to protect and adhere to bodily structures, stones, or foreign
bodies.[18] Biofilms also involve various pathogens of relatively low virulence
and 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 2 weeks. Patients with
frequent catheter-associated UTIs may therefore benefit from more frequent
catheter changes.

History and Physical

Given their frequency in hospitals, UTIs (especially complicated UTIs) remain a

clinical entity, causing considerable confusion and 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
beginning treatment, although that is not always possible. The urine sample
almost always shows an abnormal red or white cell count, positive nitrites, and
bacteria.

Any UTI that fails to resolve with first-line therapy or occurs in a high-risk patient
population should be considered a complicated UTI. Complicated UTI symptoms
include all of those listed above, as well 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 older individuals) and high-risk patient populations (pregnancy,
immunocompromised state, renal transplantation, abnormal urinary function as
in patients with neurogenic or dysfunctional bladders, immediate post-urological
surgery, renal failure, pediatrics, etc).[8]

Complicated UTIs may also present with nonspecific symptoms, atypical

presenting features (delirium in older individuals), signs mimicking an acute
abdomen, triggers for precipitating diabetic emergencies (diabetic ketoacidosis),
and even an absence of symptoms (asymptomatic bacteriuria in pregnancy).
Severe complicated UTIs can present as undifferentiated sepsis or even septic
shock.
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 UTI.[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. 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 4-glass test or even the shortened 2-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.

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]

Older patients, especially those with dementia, are at increased risk for
complicated UTIs.[29] Dementia can cause a decline in personal hygiene and an
increase in 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.[30]

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

Radiological investigations are not helpful in initially diagnosing 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 be helpful 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 complex or
intractable cases, even if the ultrasound is negative, as the results can sometimes
be life-saving.[31]
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 must do so with an ultrasound or CT scan.[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] Alternatively, nonseptic-stable
patients may be treated as outpatients.

Broad-spectrum, empiric antibiotics should always be switched to a targeted

narrow-spectrum antibiotic 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
identify 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 rechecked for urinary blood 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). To guarantee good bladder
drainage, a temporary Foley catheter is often recommended for these patients if
they are septic, particularly if they have increased post-void residual volumes.

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, prostatitis should be suspected and treated accordingly, especially if
the same organism is encountered.

Most (97%) of patients with mild or moderate pyelonephritis without major

comorbidities can be managed as outpatients after initial parenteral
antimicrobial therapy and a short observation period.[41]

Men presenting with recurrent UTIs or bacterial prostatitis may require 4 to 6

weeks or longer to eradicate their infecting bacteria completely. Men with benign
prostatic hyperplasia (BPH) and recurrent or intractable UTIs 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 performed for diagnosis, and immediate surgical
drainage performed if an obstructed, infected kidney is found (either by double J
stenting or a percutaneous nephrostomy).

Treatment success involves proper antibiotic selection, appropriate dosage

adjustment, and correct duration of therapy. Eradicating high-risk factors
whenever possible, such as removing infected stones or indwelling catheters, is
also warranted.

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 50 mg/d, 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 tend to have fewer infections if converted to a suprapubic tube.
[45] Changing the Foley is recommended to eliminate the contaminated biofilm
and reduce recurrences if a catheterized patient develops an infection.[8]

Mandelamine is a twice-daily medication that, in acidic urine, is converted to

formaldehyde, a potent urinary antiseptic. This can be useful in patients with
multidrug-resistant infections or persistently elevated postvoid residuals instead
of prophylactic antibiotics.[46] It is often given together with ascorbic acid (1000
mg twice daily) to help maintain urinary acidity, which is necessary to produce
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 efficacy in

treating complicated or recurrent UTIs.[48][49][50] Probiotics have not shown
any significant benefit compared with placebo in treating complicated UTIs.[51]

Fosfomycin has shown good activity in patients with urinary tract stones.[52]
[53] It has significant penetration inside urinary calculi and was more effective
than cefuroxime.[53] Fosfomycin is also being used parenterally as empiric
therapy for complicated UTIs in some parts of the world but not widely yet in the
US.[54][55] It is suggested that its use be limited to cases where carbapenems
cannot be used 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 frequent recurrences, especially in patients already
performing intermittent self-catheterization. The most commonly used
antimicrobial for this purpose is a gentamicin solution.[56] The recommended
dosage is to instill 30 cc to 60 cc of a solution of 480 mg gentamicin/1 liter of
normal saline after draining the bladder.[57] When introduced in this fashion,
gentamicin has no significant systemic absorption, so 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.[56][58]

Neomycin alone showed no efficacy in controlling bacteriuria, but chlorhexidine

and povidone-iodine have been shown to reduce UTIs and bacteriuria.
[56] Neosporin can also be used as a short-term (10-day) continuous bladder
irrigation with a 3-way Foley catheter.[59] Bladder antibiotic installations are
particularly useful in dialysis and anuric patients because they are not dependent
on the 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.[60]

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%. A discussion
with a local infectious disease specialist can help determine the best initial
empiric approach for the specific local community. Generally, parenteral
antibiotics are recommended for patients with systemic or severe illness 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. (Due to its greater activity, piperacillin-tazobactam is preferred
if Enterococcus, Staphylococcus, or Pseudomonas is suspected.)

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 ESBL-
producing organisms) and vancomycin (for MRSA). Ertapenem generally has
little activity against Pseudomonas and would not be an appropriate choice.

Newer Antibiotic Agents For Multidrug-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 new antibiotics and combinations,
such as:

Aztreonam/avibactam

Cefepime-enmetazobactam

Cefepime-zidebactam

Cefiderocol

Ceftazidime/avibactam

Ceftolozane/tazobactam

Eravacycline

Glycylcyclines

Imipenem/relebactam

Meropenem/vaborbactam

Omadacycline

Plazomicin

Tebipenem[61][62]

Ceftazidime/avibactam combines a potent third-generation cephalosporin with

a beta-lactamase inhibitor 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.[63][64]

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, providing very high intracellular
concentrations of medications.[65] It is well tolerated and active against many
multidrug-resistant organisms, including those resistant to carbapenem
antibiotics.[66] It is intended only for limited use as a last-resort option for
multidrug-resistant infections. While promising, some bacterial isolates have
already demonstrated resistance, so usage is limited.[65]

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.[67][68]

Plazomicin is a unique, FDA-approved injectable aminoglycoside specifically

developed for multidrug-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.[69][70][71]
Tebipenem is an oral carbapenem that has shown equivalence (non-inferiority)
to parenteral ertapenem in treating susceptible organisms causing pyelonephritis
and other complicated UTIs.[72] It will probably be the first available oral
carbapenem when it receives FDA approval.

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 2 days after initial insertion

One UTI symptom (dysuria, urgency, or frequency) or sign (fever, chills,

suprapubic pain, costovertebral angle tenderness, or flank pain)

Older patients may present with altered mental status or hypotension

Urine culture with at least 1000 CFU/mL of a single bacterial

species/pathogen[73][74][75]

The US Centers for Disease Control and Prevention (CDC): National Health Safety
Network (NHSN) defines CAUTI 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 2 different organisms.[76] This definition does not
consider other potential sources of fever, so many experts feel this definition is
less useful and tends to overestimate the actual CAUTI rate.[77] Therefore, the
IFDSA definition is usually preferred in clinical practice.

Between 15% to 25% of all hospitalized patients will have a urinary catheter at
some time during their hospital stay. It is estimated that 21% to 50% of such
catheters are unnecessary and do not meet guidelines for initial placement.
[78] The CDC has estimated that from 17% to 69% of all CAUTIs are preventable
with optimally applied infection control measures. This means up to 9000 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 50% are in long-term care centers.[79]
[80] According to the NHSN, this amounts to about 450 000 CAUTI events annually,
with 13 000 deaths and a total annual cost of $340 to $450 million.[81]

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 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 before specimen collection. If it is
necessary to collect a sample without removing the catheter, a designated
drainage system side port access is suggested. If none of these techniques are
possible, the last resort is to separate the catheter from the drainage system.
Urine cultures should not be obtained from the drainage bag.[82] For patients
with a condom catheter, a clean-catch midstream specimen is preferred.[83] If
this is not obtainable, the sample 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%).[84]

The most common organisms causing CAUTIs include E. coli (24%), Candida or
yeast (24%), Enterococcus (14%), Pseudomonas (10%), and Klebsiella (10%). Many
organisms are becoming increasingly resistant to antibiotics, including
fluoroquinolones, third- and fourth-generation cephalosporins, aminoglycosides,
and carbapenems.[85]

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 minimal to no effect in reducing urinary
bag bacteriuria.[86] The most effective agents are 1/4% acetic acid, diluted
household white vinegar (1:3 dilution), and household bleach (1:10 dilution).[87]
[88] Diluted vinegar is the most effective in dissolving calcium phosphate grit,
precipitate, and debris, which clogs catheters and bags and 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 IFDSA guidelines advise against the routine addition of antiseptics
to the drainage bag of catheterized patients because of a lack of proven efficacy.
[74] 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 antireflux 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[88][89][90]

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.[80]

Additional helpful measures to minimize CAUTIs include:

Requiring mandatory educational programs for all health care workers

involved in urinary catheter insertion or care

Strictly adhering 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
 Using 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

Strictly adhering to guidelines for diagnosing and treating CAUTIs to avoid

overtreating asymptomatic bacteriuria

Minimizing unnecessary urine cultures, which often produce positive

cultures even in uninfected patients, is a strong temptation for
inappropriate antibiotic use

Obtaining urine cultures when treating patients for a UTI so culture results
are available if the initial treatment fails

Following guidelines for correct specimen collection procedures for

urinalyses and cultures

Carefully investigating 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 in patients with long-term

catheters, usually older women with constipation. Dietary tryptophan is broken
down in the intestinal tract into indole, which the liver absorbs and converts into
indoxyl sulfate. 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 causes the intense purple color.[91][92][93] Treatment
generally includes changing the catheter and bag, treating constipation, avoiding
dehydration, and reassuring the nursing staff.

Spinal cord injury patients with catheters offer unique challenges in

diagnosing, preventing, and treating CAUTIs. Many of these patients require
permanent or intermittent catheterization, which leads to a high incidence of
asymptomatic bacteriuria that does not require treatment.[94] Impaired patient
sensation may delay the appearance of pertinent, relevant symptoms. The
development of non-specific symptoms such as fever, 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.[95]

At least 35% of spinal cord injured patients diagnosed and treated for CAUTI are
estimated to have only asymptomatic bacteriuria.[96] 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.[74]

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.
[97][98]
There is some evidence that long-term use of nitrofurantoin and D-mannose
prophylaxis can effectively reduce CAUTI in spinal cord-injured patients.[99]
[100] Silver and hydrophilic-coated catheters also appeared to help reduce
CAUTIs, but the studies were small and not considered definitive.[101]
[102] Cranberry supplements and other nutraceuticals have demonstrated either
no activity or conflicting results in reducing CAUTIs in this population.[103][104]

A guidelines-based model for ordering urine cultures and antibiotics has

significantly reduced overdiagnosis and overtreatment of asymptomatic
bacteriuria in long-term catheterized patients by over 70%.[105][106]

UTIs in Pregnancy

Between 2% and 7% of pregnant women will develop asymptomatic bacteriuria,

usually early in their pregnancy.[94] Patients with a history of prior UTIs,
diabetes, a larger number of prior deliveries, and lower socioeconomic status are
at higher risk.[107] Without treatment, up to 35% will progress to a symptomatic
UTI and/or pyelonephritis during the pregnancy.[108] Most studies suggest
untreated bacteriuria during pregnancy is associated with an increased risk of
low birth weight babies, prematurity, preeclampsia, and perinatal mortality.[107]
[109][110] Pyelonephritis has also been associated with poor pregnancy
outcomes, particularly prematurity.[111] Treatment of asymptomatic bacteriuria
and cystitis generally includes 3 to 7 days of amoxicillin-clavulanate, cephalexin,
cefpodoxime, or a single dose of fosfomycin.[112] Nitrofurantoin and
sulfamethoxazole/trimethoprim may also be used but not during the first
trimester or close to term.[108][113][114]

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.[115] 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 decrease urinary excretion of
antibiotics, but other factors also play a role.[116] 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][117][118][119] People with
diabetes who have glucosuria will demonstrate increased bacterial adherence to
the detrusor urothelium as well as decreased neutrophil efficacy.[120]

Diagnosing a UTI in dialysis patients can be challenging, as 30% to 40% of patients

will typically demonstrate pyuria without infection.[121] 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.
[122]

Antibiotics must 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. 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%) dose.[123]
[124][125] Ertapenem has a renal failure- and dialysis-suggested dosing schedule,
but neurotoxicity has been reported even when using the recommended dosages.
[126] Moxifloxacin can be used in patients with 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, even in severe

renal failure. These include:

Azithromycin

Ceftriaxone

Clindamycin

Doxycycline

Fosfomycin

Linezolid

Nafcillin

Rifampin

Trimethoprim

For patients with severe renal failure (<30 mL/min.), nitrofurantoin,

aminoglycosides, and methenamine should not be used. Preferred agents for a
UTI in such patients would be trimethoprim or fosfomycin. Other agents that can
be used include carbapenems, cephalosporins, doxycycline, penicillins, and
quinolones.

For patients with end-stage renal failure, quinolones (ciprofloxacin, levofloxacin)

are considered first-line agents for UTIs. Cefdinir and cefpodoxime as considered
second-line backup therapy.[127][128]

Intermittent bladder instillations of antibiotics (gentamicin, tobramycin,

amikacin, neomycin/polymyxin B/bacitracin) or antiseptic (povidone-iodine)
solutions can be helpful in patients with severe or end-stage renal failure, those
who have minimal urinary volume, are already performing intermittent self-
catheterization, or where alternative means have not been successful.[56]
[57] 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.
[129][130][131]

UTIs in Renal Transplants

Diagnosing a complicated UTI can 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 are more likely to be associated
with a UTI than acute rejection. Therefore, renal transplant UTI patients with
systemic signs of infection, such as fever or graft tenderness on palpation, should
have blood cultures and standard urine cultures taken. About 9% of blood
cultures will ultimately return positive for bacteremia.[132] 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 6 months after the transplant.[133] (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 increase in kidney transplant patients as
the required immunosuppression increases infection risk and interferes with
therapy.[134][135] The current 1-year mortality from infectious complications in
renal transplant recipients is <5%, having dropped from almost 50% historically,
mostly due to advances in surgical techniques and postoperative care.[136]

UTIs are most common during the first year after transplantation and will occur
in approximately 25% of transplant recipients during that time.[132][137] About
7% of renal transplant recipients will develop recurrent UTIs associated with an
increased risk of multiple antibiotic resistance, transplant failure, and death.
[138] Ascending UTIs with the early progression to frank pyelonephritis are more
common in renal transplant recipients as they have very short ureters and will
often lack an effective antireflux 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.[139]

Screening for asymptomatic bacteriuria immediately posttransplantation for the

first 90 days is controversial, as many experts recommend it while others do not.
[140][141] There is no good data suggesting that screening or treating
asymptomatic bacteriuria during the first 3 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.[142]

Screening for asymptomatic bacteriuria after the first 3 months is not

recommended as treatment beyond this point has not been effective in UTI
prevention or graft preservation and may lead to unnecessary antibiotic use and
increased bacterial resistance.[143][144] 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.[145]
[146]

Posttransplantation 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.[147][148][149]

Antibiotic UTI prophylaxis is commonly used for the first 6 to 12 months

posttransplantation.[150] Some experts continue the prophylaxis indefinitely.
[151] 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.[152] Methenamine hippurate (1000 mg twice
daily) with or without vitamin C (1000 mg twice daily) has also been used
successfully for UTI prophylaxis in renal transplant patients.[153][154] Further, it
can be safely used in patients with a creatinine clearance of >10 mL/min but
should not be used 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 this
population's UTI/asymptomatic bacteriuria treatment.[144][155]

There is an increased incidence of Klebsiella pneumoniae being the infecting

organism in renal transplant patients.[135] 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.[156]

Simple cystitis is typically treated for 10 to 14 days. (Nitrofurantoin may be used if

the GFR is ≥30 mL/min.)[157][158][159] 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 of treatment. Trimethoprim-sulfamethoxazole would be less ideal if the
local resistance prevalence is reported as ≥20%.[160][161][162]

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.[163][164][165] A non-contrast CT scan
is a reasonable next step if the ultrasound is negative, 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 identify reflux, and urodynamics will
diagnose bladder dysfunction and outflow obstruction.

Specific Infections

Emphysematous cystitis is a lower UTI 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, Pseudomonas, Clostridium, and
rarely Aspergillus and Candida.) Infrequently, infectious colitis has caused
emphysematous cystitis without clinical signs or evidence of a UTI.[166] It
typically develops in people with diabetes, females more than males, older
individuals, and those with some 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.[167] The mean age of
presentation is about 68 years, and approximately 50% of patients will have 2 or
more significant comorbidities. One-third of patients will present with sepsis, 25%
with abdominal pain, 17% with UTI symptoms, 6% with hematuria, and 8%
asymptomatic with incidental findings on an imaging examination.[168] While
the diagnosis can sometimes be made by ultrasound or plain KUB x-ray, most are
identified by CT scans. Treatment primarily involves 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.[168]

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. Most patients with the
condition have diabetes (95%), which is 6 times more common in women than
men. It is also associated with renal failure, obstruction, polycystic kidneys, and
an immunocompromised state.[169][170] Poor prognostic factors include
azotemia, thrombocytopenia, shock, hyponatremia, confusion, and
hypoalbuminemia.[171] 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 generally recommended if there are
multiple risk factors in a non-functioning kidney or if the patient is not
responding to conservative measures.[171][172]

Pyonephrosis (obstructive pyelonephritis) describes an acutely infected,

hydronephrotic kidney with usually 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. Pyonephrosis is considered an urgent surgical emergency as patients
rapidly progress to urosepsis, shock, and death. The urine may sometimes not
show any obvious signs of infection if the affected renal unit is obstructed.
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.[172]
[173] Known risk factors include a history of nephrolithiasis, diabetes (especially
poorly controlled), elevated C-reactive protein, positive urinary nitrites, larger
stone size (>5 mm), and peri-renal fat stranding.[174]

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.[175] A particularly large collection of
stones should also be initially drained and managed percutaneously.[173]
[176] It has been suggested that definitive stone surgery be conducted within 3
weeks of ureteral stent placement. Complications, specifically reduced
postoperative UTIs, are minimized if the stone removal operative time is <75
minutes.[177]

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 a 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.[178]
[179] One way to differentiate them is that xanthogranulomatous pyelonephritis
(xanthoma) cells will stain positive for periodic acid-Schiff (PAS).[180] Initial
treatment involves antibiotics and drainage, but surgical excision (focal or, more
often, total) is usually necessary for a cure.[180] Laparoscopic and robotic surgery
is possible but can be difficult even for experienced surgeons, so an open
approach is usually recommended.[179]

Other specific infections involving the urinary tract are best found in our
companion articles on those specific topics. These 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, coatings,
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.[181] Bacteriophages (viruses that attack only specific
bacteria) have been used anecdotally but successfully on a very limited basis for
highly resistant infections.[95][182][183] 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 them. They are also unaffected by bacterial antibiotic resistance
mechanisms.[95][184]

Differential Diagnosis

The differential diagnosis of a complicated UTI includes:

Abscess

Acute pyelonephritis

Bladder cancer

Chlamydial genitourinary infection

Cystitis

Focal nephronia

Herpes simplex

Interstitial cystitis

Obstructive pyelonephritis

Pelvic inflammatory disease

Prostatitis

Sexually transmitted infections

Urethritis

Urolithiasis

Vaginitis

Prognosis

The FDA recommends the use of dual primary endpoints to determine the
eradication of complicated UTIs: both a clinical response (symptom resolution
with no new UTI symptoms) AND a microbiological response (urine culture
demonstrating <1000 CFU/mL).[8]
Complications

Inadequate treatment of complicated UTIs will increase the likelihood of an early

recurrence or even an outright failure of therapy. The infection can spread to
other organs, result in an abscess, or progress to sepsis and sometimes death.

Deterrence and Patient Education

Patients should be informed of the correct use of antibiotics regarding dosing and
completing the full treatment schedule even if they feel better, incorporating
reasonable prophylactic lifestyle measures, and avoiding inappropriate
antimicrobial drug use.

Pearls and Other Issues

Diagnostic Pitfalls

UTIs are primarily a clinical diagnosis, and expert opinion should be sought
before initiating treatment of an isolated positive result in an otherwise
asymptomatic patient.

Often, clinicians treat a positive culture report rather than a patient with a
genuine UTI. Usually, a positive culture in an asymptomatic patient can be
traced to a poor sampling technique.

Another confusing scenario is that of a septic, delirious older individual who

cannot provide a history or demonstrate adequate examination signs to help
localize a septic source. These patients are often treated as having a
presumed UTI without a clear alternative septic source.

UTI-associated radiological changes can sometimes take several months to

resolve and must be interpreted with care in recurrent or persistent
infections.

UTI must be considered in the differential diagnosis of a patient with pelvic

inflammatory disease or an acute abdomen.

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

Interstitial cystitis is frequently misdiagnosed and treated as a UTI and must

be considered an alternative diagnosis in patients who repeatedly present
with cystitis symptoms and negative 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 UTIs, 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 patients who fail to improve on
appropriate antibiotics.

Management Pitfalls

Frail, older, or debilitated patients with nonspecific signs such as unexplained

falls or changes in mental status are often suspected of having a UTI. While this is
correct, such nonspecific changes are unreliable predictors of a UTI, and
antibiotics may not help unless urine studies confirm the UTI.[185][186]

Multidrug-resistant infections are becoming a major source of in-hospital

morbidity and mortality. Suppressive antibiotic regimens are sometimes used in
poorly responding or resistant cases. A dedicated infectious disease team should
optimally guide these care plans, as long-term suppressive antibiotics have
unique 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. Occasionally, 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 with radiotherapy) and do not
always indicate a genuine UTI. Long-term prophylaxis with nitrofurantoin is
associated with hypersensitivity pneumonitis. Patients should be counseled
accordingly.

Identifying predisposing factors for the infection and correcting them, if possible,
is helpful. 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 should 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 consult your local infectious disease
specialists for assistance. Their primary mission is optimally managing
complicated, challenging, and complex infections.

Enhancing Healthcare Team Outcomes

The management of complex UTIs is best performed by an interprofessional team

that may include a urologist, nephrologist, infectious disease expert, internist,
primary care clinicians, pharmacist, and nurses. Health care professionals need a
range of clinical skills. Physicians must be adept at diagnosing and managing
these infections, including interpreting diagnostic tests and selecting appropriate
antibiotics. Nurses require expertise in administering medications, providing
wound care, and monitoring patients for signs of sepsis. Pharmacists play a vital
role in optimizing drug therapy and ensuring appropriate antibiotic
stewardship. All team members share the responsibility of patient education,
infection prevention, and monitoring for treatment response.

A well-defined management strategy is essential. This includes establishing

evidence-based clinical guidelines and treatment protocols prioritizing patient
safety, infection control, and antimicrobial resistance considerations. Strategies
should also encompass prevention efforts, such as catheter care and hygiene
education.
Complicated UTIs need to be treated more carefully to serve patients with these
infections and avoid overuse and misuse of antibiotics that will ultimately result
in more resistant infections. Using the right antibiotic for the appropriate
duration is critical. Practitioners should not hesitate to use 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
catheter and appropriate imaging tests can identify these problems. These
patients need close monitoring because of potential complications. The outlook
for patients with severe complicated UTIs is guarded, and even those who recover
tend to have a prolonged recovery period.[67][187][188]

Effective communication and collaboration among health care professionals are

crucial for patient-centered care. Physicians, advanced care practitioners, nurses,
pharmacists, and other team members must share information about the
patient's condition, treatment plan, and complications. Clear and timely
communication enhances coordination, reduces errors, and promotes safer care.
The team should work collaboratively to develop comprehensive care plans that
address the infection, underlying conditions, and any potential complications.
This includes clear roles and responsibilities, regular team meetings, and
seamless transitions of care between different settings.

Team performance can be improved through ongoing education and training in

infection management, multidisciplinary collaboration, and communication
skills. Regular debriefings, case discussions, and quality improvement initiatives
can help interprofessional teams continually refine their approach to complicated
UTIs, leading to better outcomes and patient safety.

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