UTIs in Dialysis Patients Are Considered Complicated UTIs
Yes, urinary tract infections in dialysis patients should be classified and managed as complicated UTIs due to the presence of multiple host-related complicating factors that increase the risk of treatment failure.
Why Dialysis Patients Have Complicated UTIs
Dialysis patients meet several criteria that define a complicated UTI according to current guidelines:
- Immunosuppression is a host-related factor that defines a complicated UTI, and dialysis patients have impaired immune function 1
- Healthcare-associated infection risk is a host-related factor that defines a complicated UTI, and dialysis patients have frequent healthcare contact 1
- Incomplete voiding and urinary retention are common in dialysis patients due to uremic neuropathy, which is a factor that defines complicated UTI 1
- The pathophysiology and treatment of complicated UTIs are driven more by host factors than by pathogen attributes, making dialysis patients particularly vulnerable 2
Clinical Management Implications
Dialysis patients with UTI require the same aggressive approach as other complicated UTIs:
- Always obtain urine culture and susceptibility testing before initiating treatment to guide antibiotic selection 1
- Use combination empiric therapy with amoxicillin plus an aminoglycoside, OR a second-generation cephalosporin plus an aminoglycoside, OR an intravenous third-generation cephalosporin for patients with systemic symptoms 3
- Treat for 7-14 days rather than the shorter courses used for uncomplicated UTIs 1
- Expect broader microbial spectrum with higher likelihood of antimicrobial resistance, including ESBL-producing organisms 4, 5
Important Diagnostic Considerations
Urinalysis has poor diagnostic accuracy in dialysis patients:
- Pyuria (>5 WBC/HPF) has sensitivity of 82-89% but specificity of only 53-55% in hemodialysis patients 6
- Nitrites have high specificity (94%) but very poor sensitivity (14-20%) in this population 6
- Urine culture must be obtained to guide treatment rather than relying on urinalysis alone 6
Common Pitfalls to Avoid
- Do not treat dialysis-associated UTIs as uncomplicated infections with short-course antibiotics like nitrofurantoin or fosfomycin, as this leads to treatment failure 1, 5
- Do not rely solely on urinalysis to diagnose or exclude UTI in dialysis patients—always obtain culture 6
- Do not use ciprofloxacin empirically if the patient has used fluoroquinolones in the last 6 months or if local resistance rates exceed 10% 3
- Address any underlying urological abnormalities as part of the treatment plan 3