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Urinary tract infections (UTIs) represent a heterogeneous group of disorders involving infection of all or part of the urinary tract. In the United States, UTIs result in more than 10 million outpatient healthcare encounters and approximately 1 million emergency department (ED) visits each year.1 Females are much more commonly affected than males. While the diagnosis and treatment of UTIs may seem like routine tasks for urgent care (UC) clinicians, effective management of the full spectrum of urinary tract conditions and their mimics presents a variety of challenges. Proper management of UTIs will decrease treatment failures, bouncebacks, and complications. By being familiar with atypical presentations and knowing when more extensive workup is indicated, clinicians can optimize outcomes and minimize errors in the management of UTI.
UTIs are divided into those involving the lower tract and those involving the upper tract. Lower tract infection is confined primarily to the urinary bladder and is termed cystitis. Infection of the upper urinary tract is termed pyelonephritis and indicates involvement of the kidney and ureter. Pyelonephritis is characteristically more severe than cystitis, and patients with pyelonephritis frequently have systemic symptoms and appear more ill.
UTIs are also classified as uncomplicated versus complicated. This classification is not specifically anatomic or physiologic, but more generally attempts to discern which patients are most likely to recover uneventfully with therapy (uncomplicated) versus patients who are at an increased risk of treatment failure (complicated). Patient comorbidities are the primary determinants of whether a UTI is complicated versus uncomplicated.2
The frequency and relatively benign course of most UTIs may lull UC clinicians into the false perception that these are always simple cases. While most UTIs are straightforward to diagnose, patient comorbidities, local bacterial susceptibility patterns, and available antibiotic choices and costs must be considered to ensure an optimal outcome.
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Following are the most informative references cited in this paper, as determined by the authors.
2. * Takhar SS, Moran GJ. Diagnosis and management of urinary tract infection in the emergency department and outpatient settings. Infect Dis Clin North Am. 2014;28(1):33-48. (Review) DOI: 10.1016/j.idc.2013.10.003
20. * Fairley KF, Carson NE, Gutch RC, et al. Site of infection in acute urinary-tract infection in general practice. Lancet. 1971;2(7725):615-618. (Prospective study; 78 patients) DOI: 10.1016/s0140-6736(71)80066-1
34. * Gupta K, Hooton TM, Naber KG, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: a 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis. 2011;52(5):e103-e120. (Guidelines) DOI: 10.1093/cid/ciq257
38. * Naber KG, Bergman B, Bishop MC, et al. EAU guidelines for the management of urinary and male genital tract infections. Urinary Tract Infection (UTI) Working Group of the Health Care Office (HCO) of the European Association of Urology (EAU). Eur Urol. 2001;40(5):576-588. (Guidelines) DOI: 10.1159/000049840
41. Meyrier A. Sampling and evaluation of voided urine in the diagnosis of urinary tract infection in adults. UptoDate. Updated July 12, 2021. Accessed August 10, 2022. (Review)
74. Melia M. Pyelonephritis, Acute, Uncomplicated. Johns Hopkins Medicine POC-IT Guides. Updated August 3, 2016. Accessed August 10, 2022. (Online reference guide)
87. Scottish Intercollegiate Guidelines Network. Management of suspected bacterial urinary tract infection in adults. Updated September 2020. Accessed August 10, 2022. (Guidelines)
91. Habak PJ, Griggs RJ. Urinary tract infection in pregnancy. In: StatPearls. Updated July 5, 2022. Accessed August 10, 2022. (Review)
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Keywords: urinary tract infection, UTI, cystitis, pyelonephritis, bacteriuria, hematuria, urethritis, prostatitis, lower tract UTI, upper tract UTI, complicated UTI, uncomplicated UTI, pyuria, dysuria, renal stone, renal calculi, nephrolithiasis, benign prostatic hypertrophy, BPH, STIs, sepsis, SIRS, urine culture, urine dipstick, urinalysis, nitrites, leukocyte esterase, antibiogram, antibiotics, TMP-SMX, nitrofurantoin, multidrug-resistance, E coli, Klebsiella, Proteus, E faecalis
Keith Pochick, MD, FACEP
Attending Physician, Urgent Care
Cesar Mora Jaramillo, MD, FAAFP, FCUCM; Aimee Mishler, PharmD, BCPS
September 1, 2022