From the Guidelines
To assess a urinary tract infection (UTI), start with a thorough history focusing on urinary symptoms including dysuria, frequency, urgency, hematuria, suprapubic pain, and flank pain, as recommended by the European Association of Urology guidelines on urological infections 1.
Key Components of UTI Assessment
- Ask about fever, which may indicate upper tract involvement
- Inquire about risk factors such as recent sexual activity, previous UTIs, pregnancy, diabetes, immunosuppression, and catheter use
- Physical examination should include vital signs, abdominal examination for suprapubic tenderness, and costovertebral angle tenderness which suggests pyelonephritis ### Diagnostic Testing
- Diagnostic testing should include urinalysis looking for pyuria (>10 WBCs/hpf), bacteriuria, leukocyte esterase, and nitrites
- However, as noted in the guidelines for the prevention, diagnosis, and management of urinary tract infections in pediatrics and adults, the diagnostic value of urinalysis for UTI is limited, and evidence-based diagnosis of UTI should be primarily based on clinical symptoms 2
- Urine culture is recommended before starting antibiotics to identify the causative organism and guide therapy, especially in complicated cases or recurrent UTIs ### Treatment
- In uncomplicated cases, empiric therapy can begin with nitrofurantoin, trimethoprim-sulfamethoxazole, or fosfomycin, as these are commonly recommended antibiotics for UTIs
- For complicated UTIs or pyelonephritis, broader-spectrum antibiotics and longer treatment courses are needed, taking into consideration the patient's specific risk factors and medical history, as outlined in the ACR Appropriateness Criteria for recurrent lower urinary tract infections in females and acute pyelonephritis 3, 4
From the FDA Drug Label
For the treatment of urinary tract infections due to susceptible strains of the following organisms: Escherichia coli, Klebsiella species, Enterobacter species, Morganella morganii, Proteus mirabilis and Proteus vulgaris It is recommended that initial episodes of uncomplicated urinary tract infections be treated with a single effective antibacterial agent rather than the combination
The assessment of a UTI involves identifying the causative organism and its susceptibility to antibacterial agents.
- Key considerations for UTI assessment include:
- Identifying the type of bacteria causing the infection
- Determining the susceptibility of the bacteria to different antibacterial agents
- Selecting an appropriate treatment based on the results of the assessment 5
From the Research
UTI Assessment
- UTI diagnosis and treatment can be complex, with various factors to consider, including patient symptoms, test results, and resistance patterns 6
- The most diagnostic symptoms of UTIs include change in frequency, dysuria, urgency, and presence or absence of vaginal discharge 6
- Dipstick urinalysis is a popular diagnostic tool, but results must be interpreted in context of the patient's pretest probability based on symptoms and characteristics 6
Treatment Options
- First-line treatments for UTI include nitrofurantoin, fosfomycin, and trimethoprim-sulfamethoxazole (when resistance levels are <20%) 6
- Nitrofurantoin is a wide-spectrum antibiotic that is often used to treat UTIs, particularly uncomplicated lower urinary tract infections 7
- Fluoroquinolones, such as ciprofloxacin, are also commonly used to treat UTIs, but resistance rates are increasing 8, 9
- Other treatment options include oral cephalosporins, such as cephalexin or cefixime, and parenteral options like piperacillin-tazobactam and carbapenems 8
Resistance Patterns
- Resistance to trimethoprim-sulfamethoxazole and ciprofloxacin is increasing, making them less effective as empiric treatments for UTIs 8, 9
- Nitrofurantoin and fosfomycin have lower resistance rates and are often recommended as first-line treatments 8, 7, 6
- ESBL-producing Enterobacteriales and carbapenem-resistant Enterobacteriales require specialized treatment, including options like ceftazidime-avibactam and meropenem/vaborbactam 8