What are the symptoms and treatment of a urinary tract infection (UTI) in an anuric patient on hemodialysis (HD)?

Symptoms and Treatment of UTI in Anuric Hemodialysis Patients

Urinary tract infections (UTIs) in anuric hemodialysis patients present with atypical symptoms and require specific diagnostic and treatment approaches, with systemic symptoms being the primary manifestation rather than typical urinary symptoms.

Clinical Presentation

Systemic Symptoms

• Fever, rigors, and chills are the most common presenting symptoms in anuric hemodialysis patients with UTI 1
• Altered mental status, malaise, or lethargy without other identified causes 2
• Flank pain or costovertebral angle tenderness may be present 2, 3
• Non-specific symptoms such as nausea, vomiting, and diarrhea may occur 3

Atypical Presentations

• Functional decline or falls in elderly patients 4
• Sepsis manifestations including hypotension and tachypnea in severe cases 1
• Symptoms may mimic other conditions, leading to delayed diagnosis 1

Diagnostic Approach

Imaging Studies

• CT scan may show perinephric stranding or other inflammatory changes in the kidney 3
• Bedside ultrasound can quickly diagnose pyocystis (bladder abscess), a severe complication in anuric patients 1

Laboratory Tests

• Blood cultures are essential as bacteremia is common in these patients 3
• Bladder washout or catheterization may be necessary to obtain specimens in anuric patients 5
• Elevated inflammatory markers (CRP, procalcitonin, WBC count) support the diagnosis 3

Treatment Recommendations

Antimicrobial Therapy

• UTIs in anuric hemodialysis patients should be treated as complicated UTIs with a 7-14 day course of antibiotics, with drug selection based on local resistance patterns and patient factors 2, 4
• First-line empiric therapy options include:
  • Cefepime 2g IV every 24 hours (adjusted for hemodialysis) 6
  • Trimethoprim-sulfamethoxazole (dose adjusted for renal function) 4
• Avoid fluoroquinolones if the patient has used them in the last 6 months 4

Special Considerations

• Antimicrobial dosing must be adjusted for hemodialysis patients 6
• For hemodialysis patients, administer antibiotics after dialysis sessions 6
• Clinical outcomes should guide treatment rather than focusing on urinary drug concentrations, which are irrelevant in anuric patients 7

Management of Complications

• Pyocystis (bladder abscess) may require drainage in addition to antibiotics 1
• Polycystic kidney disease patients have higher risk of serious complications and may require intravenous therapy 5

Monitoring and Follow-up

• Evaluate clinical response within 48-72 hours of initiating therapy 4
• Consider changing antibiotics if no improvement occurs or based on culture results 4
• Monitor for recurrence, as anuric patients may have higher rates of complicated UTIs 8

Common Pitfalls to Avoid

• Failing to consider UTI in anuric patients due to absence of urinary symptoms 1
• Delaying diagnosis due to atypical presentation 3
• Using inappropriate antibiotic dosing not adjusted for hemodialysis 6
• Not obtaining appropriate cultures before initiating antibiotics 4