• 
  

  Differentiate a contaminated urinalysis from urinary tract infection (UTI). Obtain a catheterized urine specimen when the diagnosis is in question.

  
  
• 
  

  Send a urine culture only when appropriate (pregnancy, recurrent UTI, pyelonephritis, urosepsis, immunosuppression, fever without a source, indwelling bladder catheter).

  
  
• 
  

  Treat asymptomatic bacteriuria in pregnant patients.

  
  
• 
  

  Be aware of local bacterial resistance patterns when treating UTI.

A urinary tract infection (UTI) refers to an infection anywhere in the urinary system in the presence of bacteriuria and symptoms. Cystitis is a lower tract infection of the bladder. Pyelonephritis is an upper tract infection of the kidney. An uncomplicated UTI occurs in patients without comorbidities and with an anatomically and functionally normal urinary tract. Complicated UTI occurs in patients with a functional or anatomic abnormality of their urinary tract or with the presence of serious comorbidities that place the patient at risk for serious adverse outcomes. These comorbidities include pregnancy, diabetes, immunocompromise, cancer, advanced age, and recent hospitalization or instrumentation. Anatomic factors that cause obstruction of urine flow resulting in complicated UTI include prostate enlargement, renal stones, obstructing tumors, and ureteral reflux, compression, or stricture.

UTI is one of the most common bacterial infections. In 2007, nearly 1.7 million UTIs were diagnosed in U.S. emergency departments (EDs), and 12% required hospital admission. Neonates, girls, and young women are at increased risk for infection. UTI is uncommon in young men; however, men older than 55 years have an increased risk due to incomplete bladder emptying from prostatic hypertrophy. UTI is the leading cause of sepsis in the elderly and the most common hospital-acquired infection.

The bacterial organisms that usually cause UTI are the enteric flora that colonize the perineum. Gram-negative aerobic organisms and Escherichia coli are the most common, causing more than 80% of infections. Staphylococcus saprophyticus has the ability to adhere to urinary tract tissue, even with normal urinary flow, and causes 10–15% of UTIs. Other less common causative bacteria include the gram-negative species Klebsiella, Proteus, Serratia, and Pseudomonas.

History

The patient history should be used to determine the presence of UTI, differentiation of upper versus lower tract infection, and the presence of any complicating factors. Uncomplicated cystitis symptoms include urinary frequency, urgency, dysuria, and mild suprapubic pain. Upper tract infection often begins with similar symptoms followed by pain extending to the back or abdomen and may have additional symptoms of fever and vomiting. Other important historical information includes pregnancy, recent hospitalization, immunosuppression, prostatic hypertrophy, urinary stones, and the presence of recent urinary tract instrumentation or bladder catheterization.

Physical Examination

Patients with lower urinary tract infection should be afebrile and have normal vital signs. Mild suprapubic tenderness may be present. An external genital examination should be performed to assess for extraurethral causes of dysuria. Pyelonephritis is indicated by flank tenderness over one or both kidneys. Fever and tachycardia may be present. The remainder of the examination should be directed at ruling out other diagnoses. A pelvic examination should be performed to assess for cervicitis, pelvic inflammatory disease, or pregnancy. In a male, the GU exam may reveal urethritis, epididymitis, or prostatitis. The abdominal examination should assess for possible cholecystitis, appendicitis, diverticulitis, or an abdominal mass that may be causing obstruction to urinary flow. Lung examination may reveal that fever and flank pain are due to a lower lobe pneumonia.