Urgent Care Diagnosis and Management of Urinary Tract Infections in Adults (Pharmacology CME)

Table of Contents

 

About This Course

Urinary tract infection (UTI) is a common presentation in urgent care. UTIs are categorized based on whether the upper or lower urinary tract is involved, and also as uncomplicated versus complicated. The urgent care clinician must carefully categorize the infection for appropriate management. A working knowledge of local antibiograms or at least national susceptibility patterns of the most likely pathogens is essential in treating UTI, and utilization of an antibiotic stewardship program is ideal. Certain patient populations require variations in management, including pregnant patients. This issue of Evidence-Based Urgent Care reviews the evidence to answer these key questions for the patient who presents to urgent care with a possible UTI:

Is this an upper or lower UTI?

Is this UTI uncomplicated or complicated?

Which antibiotic is appropriate to treat this patient?

Is there an anatomic or functional abnormality or other concern that would warrant imaging?

Is this a UTI mimic? Could this potentially be a more dangerous condition, or could the patient be septic?

Is this patient best treated as an outpatient, or is ED transfer for more exhaustive workup/treatment indicated?

1. About This Course
2. Case Presentations
3. Introduction
4. Anatomy and Pathophysiology
   1. Bacteriology
   2. Physiology of Urination
   3. Physiology of Bladder and Ureter Function
5. Differential Diagnosis
   1. Unclean Specimen
   2. Sterile Pyuria
   3. Noninfectious Dysuria
6. Urgent Care Evaluation
   1. Lower Versus Upper Urinary Tract Infection
   2. Complicated Versus Uncomplicated Urinary Tract Infection
   3. Recognizing Severity
   4. Physical Examination
7. Diagnostic Studies
   1. Laboratory Studies
      1. Urine Dipstick Versus Microscopic Urinalysis
      2. Urine Culture
      3. Blood Testing
      4. Blood Culture
      5. Testing for Sexually Transmitted Infections
   2. Imaging
      1. Radiography
      2. Ultrasound
      3. Computed Tomography
8. Treatment
   1. Treatment of Lower Urinary Tract Infection
   2. Treatment of Upper Urinary Tract Infection
   3. Treatment for Male Patients
   4. Pain and Nausea Control
   5. Timing of First Dose of Antibiotic
9. Special Populations
   1. Pregnant Patients
   2. Patients With Nephrolithiasis
   3. Patients With Diabetes
   4. Renal Transplant Patients
   5. Patients With Indwelling Catheters
10. Controversies and Cutting Edge
    1. Telemedicine Management of Urinary Tract Infections
    2. Genetic Factors
    3. Antibiograms
    4. Antibiotic Stewardship Programs
    5. Cranberry Juice for Prevention of Urinary Tract Infections
11. Disposition
    1. When to Transfer for Emergency Department Evaluation
    2. Follow-Up
12. Summary
13. Time- and Cost-Effective Strategies
14. Critical Appraisal of the Literature
15. 5 Things That Will Change Your Practice
16. Risk Management Pitfalls for Urinary Tract Infection
17. Case Conclusions
18. Clinical Pathways for Antibiotics for Urinary Tract Infection in Urgent Care
19. References

Case Presentations

A 21-year-old woman presents to UC with dysuria…

• She describes 3 days of dysuria and urgency. She also reports mild suprapubic pain.
• Before prescribing antibiotics, you decide to ask the patient if she is experiencing any gynecologic symptoms...

A 38-year-old woman presents to UC with a persistent fever after a recent UTI, despite being on her second course of antibiotics…

• She complains of nagging left-sided back pain.
• The patient is afebrile after taking ibuprofen prior to arrival. She is well appearing and her vital signs are normal except for slight tachycardia. Her history includes kidney stones and a tubal ligation.
• You consider antibiotic resistance, but wonder if there is more going on here…

A 23-year-old woman arrives in the UC clinic with fever, left flank pain, and recent dysuria...

• The patient denies any previous medical problems and has no other complaints.
• She is afebrile and her heart rate is 90 beats/min.
• She has slight costovertebral angle tenderness on the left.
• You suspect UTI, but wonder if you should have concern for something else…

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Introduction

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.

Clinical Pathways for Antibiotics for Urinary Tract Infection in Urgent Care

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Key References

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