Urinary tract infections are a heterogeneous group of disorders, involving infection of all or part of the urinary tract, and are defined by bacteria in the urine with clinical symptoms that may be acute or chronic. Approximately 1 million urinary tract infections are treated every year in United States emergency departments. The female-to-male ratio is 6:1. Urinary tract infection s are categorized as upper versus lower tract involvement and as uncomplicated versus complicated. The emergency clinician must carefully categorize the infection and take into account patient host factors to optimally treat and disposition patients. A working knowledge of local or at least national susceptibil - ity patterns of the most likely pathogens is essential. A variety of special populations exist that require special management, including pregnant females, patients with anatomic abnormalities, and instrumented patients.
It is a typical day in the ED: you finish taking sign out from your partner, sign on to the computer, and see the broad spectrum of complaints awaiting you on the tracking board. The first patient seems like a quick disposition: a 21-year-old woman with dysuria. She describes 3 days of dysuria and urgency and has mild suprapubic pain. But before you write her for antibiotics, you ask if she is having any gynecologic symptoms . . .
In the next room, you meet a pleasant 38-year-old woman, mother of 4 boys. She has had kidney stones in the past and a tubal ligation. She complains of persistent fever with a recent UTI, despite starting a second course of antibiotics. She has never complained of back pain, and currently she is afebrile. The patient looks well and her vitals are normal except for a slight tachycardia. While you say, “Let me grab our ultrasound machine, and I will be right back,” you wonder if this is just a case of antibiotic resistance or something else . . .
You sigh as you read the chief complaint on the next patient to be seen: a 45-year-old nursing home patient with weakness. He is a bed-bound patient with a history of a spinal cord injury, who has a Foley catheter. His vitals reveal a fever of 38.3°C, a pulse of 130 beats/min, and a blood pressure of 100/50 mm Hg. The nursing home note says only that he has become increasingly weak. The Foley is not well cared for; there is foul-smelling urine that is cloudy, with sediment in the collection bag. You begin your physical examination while having the nurse contact the nursing home for some more history. . .
You pick up 1 more patient, a 23-year-old woman with fever, left flank pain, and recent dysuria. She denies any previous medical problems, and she has no other complaints. Her examination is benign except for a fever of 39.2°C, pulse 110 beats/min, and slight costovertebral tenderness on the left. You start her IV, send the necessary labs, and walk back to your desk wondering if she is a simple UTI or more . . . .
Less than an hour into your shift and the theme is set: UTIs. You reflect on the broad spectrum of clinical presentations for UTIs and the accompanying challenges.
The diagnosis and management of urinary tract infection (UTI) seems, at first, like an ordinary task; however, effective management of the full spectrum of urinary tract conditions and their mimics presents a variety of challenges even for the most seasoned emergency clinician. Urinary tract symptoms are frequent presenting complaints, and knowing how to manage them properly will lower failures, bounce-backs, and complications. Knowing the atypical presentations and when to do a more extensive workup will maximize outcomes and minimize errors in management.
UTIs are divided into those involving the lower tract and those of 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 it involves the kidneys 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.1
The frequency and relatively benign course of most UTIs may lull the emergency clinician into the false sense that these are easy cases. While most UTIs are straightforward to diagnose, patient comorbidities, local bacterial susceptibility patterns, and available antibiotic choices and costs must be taken into account to assure an optimal outcome.
This issue of Emergency Medicine Practice takes an evidence-based approach to answering the key questions for the patient with a possible UTI:
A literature search was performed on PubMed and MEDLINE® using the following terms: urinary tract infection, combined with imaging, diagnosis, treatment, emergency department management, epidemiology, and incidence of urinary tract infections. To limit the results, filters were set: journal articles, review articles, and practice guidelines. Titles, abstracts, and full articles were reviewed for content. Within the practice guidelines, primary sources of literature were reviewed. The Cochrane Database of Systematic Reviews were also referenced. Important practice guidelines reviewed include the Infectious Diseases Society of America (IDSA) publication on uncomplicated cystitis and pyelonephritis. Findings from 6 randomized controlled trials, 6 laboratory studies, 27 prospective observational studies, 15 retrospective studies, 2 meta-analyses, 2 systematic reviews, 6 guidelines, 26 reviews, 3 textbook chapters, 2 case reports, and 2 editorials are included here. The total number of patients enrolled in included prospective and retrospective studies was 1,846,871.
The literature on UTI is extensive. No particular specialty dominates the literature on UTI. The literature spans the disciplines of emergency medicine, internal medicine, family practice, obstetrics and gynecology, urology, and infectious disease. The advantages of split ownership are volume and coverage: there is a large amount of literature, and most scenarios have been addressed. The disadvantage of split ownership is the lack of authoritative, multidisciplinary studies and consensus statements that outline specific management options for clinicians. Additionally, many of the studies of antibiotics compare in vitro susceptibilities between antibiotics but do not compare clinical efficacy.
Future evidence-based clinical guidelines and research for UTIs should include:
Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.
To help the reader judge the strength of each reference, pertinent information about the study will be included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the authors, will be noted by an asterisk (*) next to the number of the reference.
Jessica Best, MD; Derek Ou, MD; Andrew David Kitlowski, MD; John Bedolla, MD
July 2, 2014