Complicated UTI
pyelonephritis
Catheter-associated UTI (CAUTI)

yo_ M/F with PMH of , presenting with
* days constant/intermitent, progressively worsening/improving

  • CC: dysuria, urinary frequency/urgency

  • PP: fever, chills, rigors, fatigue, or malaise, Nausea and vomiting, worsening confusion, agitation, or delirium in elderly. dysuria, urinary frequency/urgency . Prostatitis (pelvic pain, retettnion, painfull ejaculation)

  • DENIES Hematuria with colicky pain (less likely nephrolithiasis),

  • Pertinent SHX: alcohol, tabacco, drugs

  • initial vitals: no hemodynamic instability, febril

  • pertinent labs: urinalysis showing pyuria and bacteriuria , leukocyte esterase and/or nitrites positive, urine culture, CBC,BMP, Blood cultures and lactate if febrile/septic, CT abd/pelvis if severe, atypical, or not improving or oncern for obstruction/abscess

  • pendidng data:

  • previous Micro:

  • Pertinent meds: Recent antibiotics, SGLT2 inhibitors (↑ UTI risk), Immunosuppressants,

  • DDX: Cystitis, nephrolithiasis, appendicitis, PID, prostatitis, diverticulitis

PE: flank pain, CVA tenderness, suprapubic tenderness

Plan

  • obtain urine and blood Cx prior to Abx

  • ABx

    • Stable, no MDR risk (abx/hospitalization ≤90 days): Ceftriaxone 2 g IV daily (alt: Ciprofloxacin 400 mg IV BID or Levofloxacin 750 mg daily)

    • Stable, non-septic WITH MDR/Pseudomonas risk (prior MDR or abx/hosp ≤90 days):Cefepime 2 g IV BID (alt: Meropenem)

    • Duration: women 5–7 days, men 10–14 days, prostatitis 2–4 weeks

    • Septic OR ESBL concern: Meropenem 1 g IV q8h + Vancomycin

    • prostatitis: usually 2–6 weeks

  • follow cultures and susceptibility

  • once afebrile step down to oral Abx (Ciprofloxacin 500 mg BID or levofloxacin 750 mg daily for 7 days or TMP-SMX|160/800 mg (DS) BID for 14 days|

  • Trend CBC, RFP, replete as needed

  • if not improving in 2-3 days or septic obtain CT A/P w/ contrast to look for complications (Renal or perinephric abscess,Emphysematous pyelonephritis,Obstructive UTI (infected stone, peostetic absscess))

  • follow up with PCP in a week

Note

  • culture Typically ≥10,000 bacteria

  • Imaging is NOT routinely indicated

  • CT if nto improving for obstruction, abscess, emphysematous pyelonephritis, perinephric fluid, renal swelling

  • MDR UTI risk factors (last 3 months): prior resistant UTI (ESBL, FQ-resistant, Pseudomonas), recent hospitalization/healthcare stay, recent broad-spectrum antibiotic use, or travel to high-resistance regions.

  • Common pathogens in complicated UTI include E. coli (most common), Klebsiella, Proteus, Pseudomonas, Enterobacter, and sometimes Enterococcus.

OutPatient Plan

  • Ciprofloxacin 500 mg PO twice daily for 7 days (or 1000 mg extended-release daily for 7 days) or Levofloxacin 750 mg PO daily for 5 days

Urine culture-> organism + susceptibility (S), resistance (R)

Urinalysis (UA) – what the numbers mean

  • WBCs (pyuria):

    • Normal: 0–5 /HPF

    • >10 /HPF → infection likely

  • RBCs:

    • Normal: 0–3 /HPF

    • ↑ → stones, infection, trauma

  • Leukocyte esterase (LE):

    • Reported as negative / trace / small / moderate / large

    • Moderate–large = significant WBCs

  • Nitrites:

    • Positive = gram-negative bacteria (e.g., E. coli)

    • Negative doesn’t rule out infection

  • Bacteria:

    • Few / moderate / many

    • Moderate–many = infection more likely

Urine culture – colony count (CFU)

  • ≥100,000 CFU/mL (10⁵) → definite infection

  • 10,000–100,000 (10⁴–10⁵) → possible (use clinical context)

  • <10,000 → usually contamination