Uncomplicated Urinary Tract Infection

Uncomplicated urinary tract infection presenting as cystitis or pyelonephritis is common and a significant cause of ill health, although there are generally few sequelae. Unfortunately, the vast body of research now accumulating on predisposing factors and bacterial virulence has had little therapeutic consequence. Nevertheless, standardisation of diagnostic criteria and formulation of guidelines on treatment will go some way to limit the anarchy of excessive investigation and over-treatment which has hitherto contributed to rising antibiotic resistance rates. Truly effective alternative treatments and prophylactic vaccines have yet to be developed.     

Diagnosis and Management of Urinary Tract Infection in Hospitalized Older People

OBJECTIVES: To compare the diagnosis and management of urinary tract infection (UTI) in hospitalized older people with clinical criteria and therapeutic guidelines.
DESIGN: A retrospective case series of emergency hospital admissions collected over an 18-month period.
SETTING: An acute general hospital in northwest England.
PARTICIPANTS: Two hundred sixty-five patients aged 75 and older with a diagnosis of UTI at hospital discharge.
MEASUREMENTS: Data relating to age, sex, presenting complaint, admission and discharge destinations, background comorbidities and medications, investigations performed, treatment given, length of stay, and complications were obtained using chart review.
RESULTS: Of the 265 patients (mean age 85.4) the overdiagnosis of UTI was common, with 43.4% of patients not meeting criteria. Only 32.1% of patients overall had any urinary tract symptoms (48.7% in the UTI group). Of the non-UTI group, 12 (10.4%) had urinary tract symptoms with a negative urine culture, 43 (37.4%) had asymptomatic bacteriuria (ASB), and 60 (52.2%) had neither urinary tract symptoms nor bacteriuria. Treatment given varied greatly. The mortality rate was 6.0%, and the average length of stay was 29.9 days (median 17.0, range 1–192). Complications were frequent, including Clostridium difficile diarrhea (8%), falls (4%), methicillin-resistant Staphylococcus aureus infection (3%), and fracture (2%).
CONCLUSION: More-reliable criteria are needed to aid the diagnosis of UTI in hospitalized older people. Better adherence to clinical management guidelines may improve outcomes.     

Pediatric Urinary Tract Infection

Urinary tract infection (UTI) in childhood affects many children but it can be difficult to diagnose, especially in infancy where it is believed that most renal damage occurs. UTI can point the way to underlying congenital abnormalities of the urinary tract which are uncommon, as are the long-term sequelae of renal scarring, hypertension and chronic renal failure. It is now appreciated that many infants have reflux associated damage before birth with associated renal dysplasia. Investigations in children with a UTI remain controversial with ultrasonography being sufficient in experienced hands and only selected patients undergoing cystography and radionuclide imaging. Gross vesicoureteric reflux (VUR) is rare and most mild to moderate VUR resolves spontaneously. Although there is no randomised controlled trial to date low dose prophylactic antibiotics are used in the majority of children in whom VUR is detected with surgery being reserved for those with problematical infections or anatomical abnormalities. Familial reflux is increasingly recognised.     

UTI and Urinary Tract Reconstruction

Reconstruction of the lower urinary tract is necessary after a variety of urological interventions. Radical cystectomy is the mainstay of treatment for muscle-invasive bladder cancer. But also neurogenic bladder dysfunction or other non-malignant diseases may require cystectomy with the need for restoration of the urinary tract. Indications for reconstruction using intestinal segments have expanded greatly. However, bowel was not meant to serve as a conduit or a storage device for urine and its incorporation into the urinary tract may result in numerous complications. Urinary diversions include incontinent stomas, continent urinary reservoirs, and orthotopic bladder substitutes. One of the major goals of urinary diversions is to prevent infectious complications and to preserve the upper urinary tract. Renal function may potentially be at risk from several factors including urinary infection, urinary tract obstruction, ureteric reflux, stone formation, and recurrent tumour formation in case of malignancy. Infections manifest themselves as bacteriuria or as acute or chronic pyelonephritis. The vast majority of conduits and most continent diversions will develop chronic bacteriuria at some stage. In contrast to orthotopic bladder substitutes which remain sterile, particularly if they are free of residual urine. The significance and consequences of bacteriuria and urinary tract infections will be discussed in this section taking into account the most common forms of incontinent, continent and orthotopic urinary diversions.     

Resistant Pathogens in Urinary Tract Infections

Antimicrobial susceptibility of bacteria causing urinary tract infection (UTI) has evolved over several decades as antimicrobial exposure has repeatedly been followed by emergence of resistance. Older populations in the community, long-term care facilities, or acute care facilities have an increased prevalence of resistant bacteria isolated from UTI. Resistant isolates are more frequent in long-term care populations than the community. Resistant isolates include common uropathogens, such as Escherichia coli or Proteus mirabilis , and organisms with higher levels of intrinsic resistance, such as Pseudomonas aeruginosa or Providencia stuartii. Isolation of resistant organisms is consistently associated with prior antimicrobial exposure and higher functional impairment. The increased likelihood of resistant bacteria makes it essential that a urine specimen for culture and susceptibility testing be obtained before instituting antimicrobial therapy. Therapy for the individual patient must be balanced with the possibility that antimicrobial use will promote further resistance. Antimicrobial therapy should be avoided unless there is a clear clinical indication. In particular, asymptomatic bacteriuria should not be treated with antimicrobials. Where symptoms are mild or equivocal, urine culture results should be obtained before initiating therapy. This permits selection of specific therapy for the infecting organism and avoids empiric, usually broad-spectrum, therapy. Where empirical therapy is necessary, prior infecting organisms should be isolated, and recent antimicrobial therapy, as well as regional or facility susceptibility patterns, should be considered in antimicrobial choice. Where empirical therapy is used, it should be reassessed 48 to 72 hours after initiation, once pretherapy cultures are available.     

Diagnosis and Management of Fungal Urinary Tract Infections

Fungal urinary infections are becoming more common, particularly in hospital settings with the vast majority caused by Candida species. The ability to differentiate colonization from infection is difficult and treatment decisions are far from straightforward. To date, there is no dependable method for distinguishing colonization from infection, as evidence of funguria does not automatically require treatment. Often, mere modification of predisposing factors is sufficient management. Following a standardized algorithm that categorizes patients with regard to symptoms and risk profiles can aid the clinician in proper workup and treatment and mitigate unnecessary antifungal usage.     

Sexual Intercourse and Risk of Symptomatic Urinary Tract Infection in Post-Menopausal Women

Background Sexual intercourse increases the risk of symptomatic urinary tract infections (UTI) in young women, but its role among post-menopausal women is unclear. Objective To determine whether recent sexual intercourse, as documented by daily diaries, is associated with an increased risk of symptomatic UTI in post-menopausal women. Design A 2-year prospective cohort study conducted from 1998 to 2002. Participants One thousand and seventeen randomly selected post-menopausal women enrolled at Group Health Cooperative (GHC), a Washington State HMO. Measurements and Main Results Women were asked to enter daily diary information on vaginal intercourse, medication use, and genito-urinary symptoms. The outcome of interest, symptomatic UTI, was defined as a positive urine culture ≥10⁵ CFU/mL of a uropathogen and the presence of ≥2 acute urinary symptoms. Nine hundred thirteen women returned diaries and were included in this study. Seventy-eight women experienced 108 symptomatic UTIs, and 361 (40%) reported sexual intercourse in their diaries. There was an increased hazard for UTI 2 calendar days after the reporting of sexual intercourse in the diaries (adjusted hazard ratio [HR], 3.42, 95% CI 1.49–7.80), while there was no evidence for an increased hazard associated with intercourse at other times. When the UTI criterion was relaxed from ≥10⁵ CFU/mL to ≥10⁴ CFU/mL, adding 9 UTI events to the analysis, the HR for UTI 2 days after intercourse changed slightly to 3.26 (95% CI 1.43–7.43). Conclusions Our data suggest that, as with younger women, recent sexual intercourse is strongly associated with incident UTI in generally healthy post-menopausal women.