Scenario UTI

Learning objective

1. Mahasiswa memahami gejala-gejala yang terjadi pada pasien UTI

2. Mahasiswa memahami patofisiologi dari gejala-gejala yang terjadi.
3. Mahasiswa memahami pemeriksaan penunjang yang diperlukan untuk menegakkan diagnosis
UTI
4. Mahasiswa memahami interpretasi dari hasil pemeriksaan penunjang tersebut
5. Mahasiswa memahami penatalaksanaan kasus UTI

Scenario

Ny beti, 36 tahun datang ke poliklinik penyakit dalam dengan keluhan sakit waktu BAK sudah 2 hari yang
lalu.

1. Klarifikasi istilah
2. Identifikasi masalah
3. Analisis masalah
a. Apa gejala UTI?
b. Apa penyebab UTI?
c. Apa factor resiko UTI?
d. Apa komplikasi UTI?
e. Apa pemeriksaan penunjang UTI?
f. Cara penegakan diagnosis
g. Apa penataksanaannya
4. Kerangka konsep
5. Hipotesis
6. Sintesis
A. Gejala UTI

usually begin suddenly and may include one or more of the following signs:

 The urge to urinate frequently, which may recur immediately after the bladder is emptied.
 A painful burning sensation. (If this is the only symptom, then the infection is most likely
urethritis, an infection limited to the urethra.)

 Discomfort or pressure in the lower abdomen. The abdomen can feel bloated.
 Cramping in the pelvic area or back.

 The urine often has a strong smell, looks cloudy, or contains blood. This is a sign of pyuria, or
a high white blood cell count in the urine, and is a very reliable indicator of urinary tract infections.

 Occasionally, fever develops.

Symptoms of Severe Infection in the Kidney (Pyelonephritis)

Symptoms of kidney infections tend to affect the whole body and be more severe than those of
cystitis. They may include:

 Symptoms of lower UTIs that persist longer than a week. (Sometimes lower UTI symptoms may
be the only signs of kidney infection. People at highest risk for such "silent" upper urinary tract
infections include patients with diabetes, impaired immune systems, or a history of relapsing or
recurring UTIs.)
 An increased need to urinate at night.

 Chills and persistent fever (typically lasting more than 2 days).

 Pain in the flank (pain that runs along the back at about waist level).

 Vomiting and nausea.

Symptoms of UTIs in Infants and Toddlers

UTIs in infants and preschool children tend to be more serious than those that occur in young women, in
part because they are more likely to occur in the kidneys and upper urinary tract. (Older children are
more likely to have lower urinary tract infections and standard symptoms.) Infants and young children
should always be checked for UTIs if the following symptoms are present:

 A persistent high fever of otherwise unknown cause, particularly if it is accompanied by signs of

feeding problems and debility, such as listlessness and fatigue.
 Painful, frequent, and foul smelling urine. (Parents are generally unable to identify a UTI just by
the smell of their child's urine. Medical tests are needed.)

 Cloudy urine. (If the urine is clear, the child most likely has some other ailment, although it is not
absolute proof that the child is UTI-free.)

 Abdominal and low back pain may be present.

 Vomiting and abdominal pain (usually in infants).

 Jaundice (yellowing of the skin and the whites of the eyes) in infants, particularly if it develops
after 8 days of age.
 B. Penyebab

The bacterial strains that cause UTIs include:

 Escherichia (E.) coli is responsible for 75 - 90% of uncomplicated cystitis cases in younger women
and in more than half the cases in older women (over age 50). In most cases of UTI, E. coli, which
originates as a harmless microorganism in the intestines, spreads to the vaginal passage, where it
invades and colonizes the urinary tract. Some bacteria may be able to invade into deeper tissue in
the bladder, where they survive to reinfect the patient after resolution of the previous infection.
 Staphylococcus saprophyticus accounts for 5 - 15% of UTIs, mostly in younger women. Infections
caused by this bacterium tend to have a seasonal variation, with a higher incidence in the summer
and fall than in the winter and spring.

 Klebsiella, Enterococci bacteria, and Proteus mirabilis account for most of remaining bacterial
organisms that cause UTIs. They are generally found in UTIs in older women.

 Rare bacterial causes of UTIs include ureaplasma urealyticum and Mycoplasma hominis, which
are generally harmless organisms.

Organisms in Severe or Complicated Infections

 The bacteria that cause kidney infections (pyelonephritis) are generally the same bacteria that
cause cystitis. There is some evidence, however, the E. coli strains in pyelonephritis are more virulent
(able to spread and cause illness).
 Complicated UTIs that are related to physical or structural conditions are apt to be caused by a
wider range of organism. E. coli is still the most common organism, but others have also been
detected, including Klebsiella, P. mirabilis, and Citrobacter.

 Fungal organisms, particularly Candida species. (Candida albicans, for example, causes the so-
called "yeast infections" that also occur in the mouth, digestive tract, and vagina.)

 Other bacteria associated with complicated or severe infection include Pseudomonas

aeruginosa, Enterobacter, and Serratia species, gram-positive organisms (including Enterococcus
species), and S. saprophyticus.

Bacterial Strains in Recurrent UTIs

Recurring infections are often caused by different bacteria than those that caused a previous or first
infection.

Even if the reinfecting bacterium is still E. coli, it may be a variant of the original infecting E. coli strain.
Such strains produce substances, such as one called P fimbriae, which tend to make the bacteria more
infectious. Uncommon causes of reinfection include Ureaplasma and Mycoplasma hominis, which are
sometimes associated with acute urethral syndrome.
 C. Factor resiko

After the flu and common cold, urinary tract infections (UTIs) are the most common medical complaint
among women in their reproductive years. Women are 30 times more likely to have UTIs than men. At
least a third of American women are diagnosed with a UTI by the time they are 24 years old. Every year,
11% of American women have at least one such infection, and up to 60% of all women will develop a UTI
at some time in their lives. A third of these women will have a recurrence within a year. Furthermore,
each year about 250,000 women develop kidney infections (pyelonephritis), and 100,000 are
hospitalized for treatment.

Specific Risk Factors in Women

Structure of the Female Urinary Tract. In general, the higher risk in women is mostly due to the shortness
of the female urethra, which is 1.5 inches compared to 8 inches in men. Bacteria from fecal matter can
be easily transferred to the vagina or the urethra.

Sexual Behavior. Frequent or recent sexual activity is the most important risk factor for urinary tract
infection in young women. Nearly 80% of all urinary tract infections occur within 24 hours of intercourse.
(Sexual activity is less associated with cystitis in women after menopause.)

UTIs are very rare in celibate women. It is important to stress, however, that UTIs are NOT sexually
transmitted infections, although these infections ( Chlamydia trachomatis, gonorrhea, or herpes simplex
virus) may increase the risk for UTIs.

In general, however, it is the physical act of intercourse itself that produces conditions that increase
susceptibility to the UTI bacteria, with some factors increasing the risk:

 Women having sex for the first time or who have intense and frequent sex after a period of
abstinence are at risk for a condition called "honeymoon cystitis."
 A sudden increase in the frequency of sexual intercourse poses a significant risk for UTI,
particularly if a diaphragm is used.

 Recent changes in sexual partners.

 Sexual position (such as the woman on top) can contribute to the risk..

Contraceptives may also contribute to risk in a number of ways:

 The spring-rim of the diaphragm may bruise the area near the bladder neck, making it
susceptible to bacteria.
 Unlubricated condoms may injure vaginal tissue and make it vulnerable to infections. (Using a
sterile water-based lubricant, such as KY jelly, may help reduce this risk. Petroleum-based lubricants
should be avoided because they weaken latex condoms.)

 Some women get UTIs as an allergic reaction to latex in condoms or to oral contraceptives.
 Use of spermicide, such as nonoxynol-9, doubles or triples a women's risk for UTI, regardless of
whether it is used with a condom or diaphragm. Spermicides also pose a risk for sexually transmitted
infections, and experts warn against their use.

Pregnancy. Although pregnancy does not increase the rates of asymptomatic bacteriuria, it does increase
the risk that it will progress to a full-blown infection. About 2 - 11% of pregnant women have
asymptomatic bacteriuria and, of those, 13 - 27% will develop a kidney infection late in their term.
(However in early pregnancy, frequent urination -- a common symptom of UTI -- is most likely due to
pressure on the bladder.)

Although all pregnant women should be tested for UTIs, women at highest risk have the following
conditions or situations:

 Diabetes
 Sickle cell trait

 Low-income

 Have had many children

 History of childhood UTIs

 Have undergone a cesarean section with catheterization of the bladder

 Have received epidural anesthesia

Women who have had a UTI before or during pregnancy also have a higher risk of developing recurrent
urinary tract infections after delivery. About 25 - 33% of women who have bacteriuria during pregnancy
will have another urinary tract infection, sometimes as many as 10 - 14 years later.

Menopause. The risk for UTIs, both symptomatic and asymptomatic, is highest in women after
menopause. Studies indicate that 20 - 25% of women over 65 years old have UTIs, and 10 - 15% have
asymptomatic bacteriuria (compared to 2 - 5% of young women). Sexual activity plays a lesser role in
UTIs in older women than in younger women. In general, biologic changes due to menopause put older
women at particular risk for primary and recurring UTIs:

 With estrogen loss, the walls of the urinary tract thin, weakening the mucous membrane and
reducing its ability to resist bacteria. The bladder may lose elasticity and fail to empty completely.
 Estrogen loss has also been associated with reduction in certain immune factors in the vagina
that help block E. coli from adhering to vaginal cells.

 Levels of lactobacilli (protective bacteria) decline after menopause, perhaps also due to drops in
estrogen.

Other aging-related urinary conditions, such as urinary incontinence, can increase the risk for recurrent
urinary tract infections.
Allergies. Women who have skin allergies to ingredients in soaps, vaginal creams, bubble baths, or other
chemicals that are used in the genital area are at high risk for UTIs. In such cases, the allergies may cause
small injuries that can introduce bacteria.

Antibiotic Use. Antibiotics often eliminate lactobacilli, the protective bacteria, along with harmful
bacteria. This can cause an overgrowth of E. coli in the vagina.

Specific Risk Factors in Men

Men become more susceptible to UTIs after 50 years of age, when they begin to develop prostate
problems. Benign prostatic hyperplasia (BPH), enlargement of the prostate gland, can produce
obstruction in the urinary tract and increase the risk for infection. In men, recurrent urinary tract
infections are also associated with prostatitis, an infection of the prostate gland that is caused by E. coli.
Although only about 20% of UTIs occur in men, these infections can cause more serious problems than
they do in women. Men with UTIs are far more likely to be hospitalized than women. [For more
information, see In-Depth Report #71: Benign prostatic hyperplasia.]

Specific Risk Factors in Children

Each year, about 3% of American children develop urinary tract infections. During the first few months of
life, UTIs are more common in boys than in girls. Boys who are uncircumcised are about 10 - 12 times
more likely than circumcised boys to develop UTIs by the time they are 1 year old. After the age of 2
years, UTIs are far more common in girls. Throughout childhood, the risk of UTIs is about 2% for boys
and 8% for girls. As with adults, Escherichia coli (E. coli) is the most common cause of UTIs in children.

Vesicoureteral Reflux (VUR). Vesicoureteral reflux (VUR) affects about 10% of all children. It is the source
of urinary tract infections in 30 - 50% of childhood cases. This is a structural defect of the valve-like
mechanism between the ureter and bladder that allows urine to flow backward, carrying infection from
the bladder up into the kidneys. VUR also puts children at risk for recurrence. Such recurrences nearly
always occur within the first 6 months after the first UTI.

Institutionalization, Catheterization, and UTI Risk

Hospitalizations and Catheters. About 40% of all infections that develop in hospitalized patients are in
the urinary tract. The organisms that cause infections in hospitals (called nosocomial infections) are
usually different from those that commonly cause UTIs. They are also more likely to be resistant to
standard antibiotics. Hospitalized patients at highest risk for such infections are those with in-dwelling
urinary catheters, patients undergoing urinary procedures, long-stay elderly men, and patients with
severe medical conditions.

About 80% of UTIs in the hospital are due to catheters. Nearly all patients who need urinary catheters
develop high levels of bacteria in their urine, and the longer the catheter is in place, the higher the risk
for infection. Catheterized patients who develop diarrhea are nine times more likely to develop UTIs than
are patients without diarrhea. In most cases of catheter-induced UTIs, the infection produces no
symptoms. Because of the risk for wider infection, however, anyone requiring a catheter should be
screened for infection. Catheters should be used only when necessary and should be removed as soon as
possible.

Nursing Homes. All older adults who are immobilized, catheterized, or dehydrated are at increased risk
for UTIs. Nursing home residents, particularly those who are incontinent and demented, are at very high
risk. Up to 40% of elderly patients who live in nursing homes will contract a urinary tract infection.

Medical Conditions that Increase the Risk for UTIs

Diabetes. Diabetes puts women at significantly higher risk for asymptomatic bacteriuria. The longer a
woman has diabetes, the higher the risk. (Control of blood sugar has no effect on this condition.) The risk
for UTI complications is also higher in people with diabetes. In fact, certain UTI-related abscesses are
reported only in patients with diabetes. These patients are also at higher risk for fungal-related UTIs.

Kidney Problems. Nearly any kidney disorder increases the risk for complicated UTIs.

AIDS and Immunosuppressed Patients. Any infection is dangerous in people whose immune systems are
damaged, and UTIs are no exception, particularly pyelonephritis.

Sickle-Cell Anemia. Patients with sickle-cell anemia are particularly susceptible to kidney damage from
their disease, and UTIs put them at even greater risk.

Kidney Stones. In some cases, kidney stones can cause urinary tract obstruction that leads to infection,
particularly pyelonephritis. Symptoms of severe urinary tract infection in people with a history of kidney
stones may indicate obstruction, which is a serious condition.

Urinary Tract Abnormalities. Some people have structural abnormalities of the urinary tract that cause
urine to stagnate or flow backward into the upper urinary tract. A prolapsed bladder (cystocele) can
result in incomplete urination so that urine collects, creating a breeding ground for bacteria. Tiny pockets
called diverticula sometimes develop inside the urethral wall and can collect urine and debris, further
increasing the risk for infection.

D. Komplikasi

Urinary discomfort and emotional distress are the primary concerns in most women with recurrent UTIs.
They can cause significant impairment of a woman's quality of life during symptom periods, and affect
social function, vitality, and emotional well-being.

Medical Complications of Urinary Tract Infections in Adults

Nearly all urinary tract infections are mild, treatable, and have no long-term consequences. Serious
physical complications can occur in some cases, however, most often in hospitalized patients.
Obstruction and Widespread Infection. Very severe upper urinary tract infections may cause obstruction
that results in widespread and even life-threatening infection. Patients who develop UTIs in the hospital
are at higher risk for such infections than those outside the hospital. In kidney infection that obstructs
the ureter, mortality rates exceed 40%. This specific condition should be suspected in people with
diabetes who have severe UTIs.

Women with diabetes have more frequent and more severe UTIs than women without the disease and
are more frequently hospitalized for kidney infections. In fact, the most serious, but rare, complications
of urinary tract infections (pyelonephritis, widespread infections, abscesses, inflammation of the bladder
wall) occur mostly in patients with diabetes.

Kidney Damage. In high-risk adults, recurrent UTIs may cause scarring in the kidneys, which over time
can lead to hypertension and eventual kidney failure. People with UTIs who develop serious kidney
disease from UTIs are likely to have other predisposing diseases or structural abnormalities. (Recurrent
urinary tract infections, even in the kidney, almost never lead to progressive kidney damage in otherwise
healthy women.)

Kidney Stones. Kidney stones can be caused by urinary tract infections (as well as increase the risk for
UTIs in the first place). Those known as struvite stones are almost always caused by urinary tract
infections due to bacteria that secrete certain enzymes. These enzymes raise urine concentrations of
ammonia, which composes the crystals forming struvite stones. [See In-Depth Report#81: Kidney stones.]

Urge Incontinence. Recurrent UTIs may increase the risk for urge incontinence after menopause. (People
with urge incontinence experience leakage and the need to urinate frequently.) [See In-Depth Report
#50: Urinary incontinence.]

Complications of Urinary Tract Infections in Pregnancy

Urinary tract infections during pregnancy pose particular risks for both mother and child:

 If asymptomatic bacteriuria is not detected and treated promptly in pregnant women, as many
as 25% develop kidney infection (pyelonephritis), which in turn increases the risk for premature
birth, infant mortality, and later chronic kidney disease.
 Even if kidney infection does not develop, untreated UTIs occurring in the first and third
trimester of pregnancy slightly increase the risk for mental retardation and developmental delay in
the infant.

 Certain strains of E. coli can increase the risk for complications during pregnancy, including
miscarriage or premature delivery, even if pyelonephritis does not develop.

 Infants of women who harbor Ureaplasma urealyticum also have an increased risk for
respiratory infections.

Complications in Children with Urinary Tract Infections

Urinary tract infections are a major cause of hospitalization in children. Untreated, they can be very
serious, particularly in children under 4 years old. Fortunately, with prompt treatment, childhood cases
of upper urinary tract infections rarely cause any serious consequences.

Spread of Infection. Widespread infection is a major complication of a primary infection. Although

laboratory tests in some infants with UTI may suggest the presence of meningitis (inflammation of the
spinal column), in most of these UTI cases the outcome is good with treatment, and there appear to be
no neurological symptoms afterward.

Kidney Scarring. Kidney scarring is the major concern in children who develop serious or recurrent UTIs.
Scarring in young growing kidneys is much more serious than in the mature kidney. Over the years, it
increases the risk for hypertension and kidney failure. In one study, evidence of scarring developed in 6%
of children who had been hospitalized for a urinary tract infection. Children most at risk for this
complication include:

 Children with vesicoureteral reflux (VUR). (Carefully managed vesicoureteral reflux without
scarring is not associated with serious complications.)
 Abnormally structured urinary tracts

 Recurrent kidney infections

 A delay in treating an acute UTI

E. Physical Examination

During an exam, the doctor should examine the pelvic and vaginal area in women. Men require a digital
rectal examination to determine if prostate enlargement is present. The doctor will also examine the
male genitals for signs of infection. In both men and women, the doctor should also check the abdomen
and areas around the kidneys for swelling and tenderness.

Dipstick Tests

Dipstick tests, available over the counter, are quite reliable in making a reasonable diagnosis of UTIs in
women with symptoms. Dipstick tests may also be useful for identifying UTIs in children and infants. The
test uses a chemical on a stick that when dipped in urine reacts to nitrites, substances produced by many
of the bacteria that cause UTIs. A positive test (which indicates that an infection is present) often
eliminates the need for urine cultures, a more expensive test used to detect bacteria. A negative dipstick
test helps to avoid unnecessary antibiotics, which are contributing to the growing problem of antibiotic
resistance. These tests are not entirely accurate, however, and studies report that they may miss up to
25% of actual UTIs. If a woman has persistent UTI symptoms, and the dipstick test is negative, she should
check with her doctor to see if more accurate tests are needed.

Urine Samples
A urine sample is needed for most extensive testing. The doctor will usually need a clean-catch sample.
There are also other methods for collecting urine, depending on the patient's condition.

Clean-Catch Sample. A clean-catch sample for UTI depends on a sample free of contaminants normally
present at the opening of the urethra (white blood cells and bacteria unrelated to UTIs). To obtain an
untainted urine sample, doctors usually request a so-called midstream, or clean-catch, urine sample. To
provide this, the following steps are taken:

 Patients must first wash their hands thoroughly, then wash the penis or vulva and surrounding
area four times, with front-to-back strokes, using a new soapy sponge each time.
 The patient must then begin urinating into the toilet and stop after a few drops.

 The patient then positions the container to catch the middle portion of the stream. Ideally, this
urine will contain only the bacteria and other evidence of the urinary tract infection.

 The patient then urinates the remainder into the toilet.

 The patient securely screws the container cap in place without touching the inside of the rim.

The sample is generally given to the doctor or sent to the laboratory for analysis.

Treatment can be started without the need for further tests if the following urinalysis results are present
in patients with symptoms and signs of UTIs:

 A high white cell count

 Cloudy urine

Treatment can be started without the need for further tests if the following urinalysis results are present
in patients with symptoms and signs of UTIs:

 A high white cell count

 Cloudy urine

F. Pemeriksaan penunjang

Imaging Techniques

Because of the expense and the limited accuracy of imaging procedures, these techniques are used only
for the following:

 Serious and recurrent cases of pyelonephritis

 When structural abnormalities are suspected
 If infections do not respond to treatment

 If a doctor suspects obstruction or an abscess

 After a first urinary tract infection in children age 2 - 24 months to detect possible obstruction or
vesicoureteral reflux. Tests include ultrasound and a voiding cystourethrogram and possibly scans.
Some evidence suggests that ultrasound is probably not necessary, but at this time it is
recommended by major medical groups.

Ultrasound. Ultrasound is a noninvasive, risk-free imaging test that can be used to screen for
hydronephrosis (obstructions of the flow of urine), kidney stones that predispose to infection, and
kidney abscesses. In men, ultrasound can detect enlargement or abscesses of the prostate and, when
combined with x-rays, is an accurate method for detecting incomplete emptying of the bladder, a
common cause of UTI in men over age 50. In children with urinary tract infections, it also can be used to
detect vesicoureteral reflux, the defect of the valve-like mechanism between the ureter and bladder.
Ultrasounds are not as accurate as voiding cystourethrograms.

Nuclear Scans. Imaging techniques called nuclear scans may be useful in certain complicated cases, such
as detecting kidney scarring after pyelonephritis in children. They produce better images and expose the
patient to far less radiation than x-rays. One such scan called dimercaptosuccinic acid (DMSA)
scintigraphy uses injections of tiny amounts of radioactive tracers. A scanning machine (scintillation or
gamma camera) is then used to detect pictures of the tracer in the kidney. This information is recorded
on a computer screen or on film.

Magnetic Resonance Imaging (MRI) or Computed Tomography (CT). Magnetic resonance imaging (MRI)
and computed tomography (CT) scans are noninvasive advanced imaging techniques that are sometimes
used when nuclear scans are inconclusive. A CT scan is useful for ruling out kidney stones or obstructions
in women with recurrent UTIs.

X-Rays. Special x-rays can be used to screen for structural abnormalities, urethral narrowing, or
incomplete emptying of the bladder, which can cause stagnation of urine and predispose to infection.

 Voiding cystourethrogram is an x-ray of the bladder and urethra. To obtain a cystourethrogram, a

dye, called contrast material, is injected through a catheter inserted into the urethra and passed
through the bladder.
 An intravenous pyelogram (IVP) is an x-ray of the kidney. For a pyelogram, the contrast matter is
injected into a vein and eliminated by the kidneys. In both cases, the dye passes through the urinary
tract and reveals any obstructions or abnormalities on x-ray images. Due to the possible risks to the
fetus, x-rays are not performed on pregnant women.

Cystoscopy. Cystoscopy is used to detect structural abnormalities, interstitial cystitis, or masses that
might not show up on x-rays during an IVP. The patient is given a light anesthetic, and the bladder is filled
with water. The procedure uses a cystoscope, a flexible, tube-like instrument that the urologist inserts
through the urethra into the bladder.

Other Diagnostic Tests for Kidney Infections and Severe UTIs

No noninvasive test will differentiate between upper and lower urinary tract infections. This is a
particular problem because of the high percentage of women whose cystitis symptoms mask infections
that also exist in the upper tract.

Antibiotic Trial. The best current test for pyelonephritis is the short-term antibiotic therapy given for
cystitis. If the infection returns within 2 weeks after treatment, an upper urinary tract infection is usually
present.

Blood Cultures. If symptoms are severe, the doctor will order blood cultures to determine if the infection
is in the bloodstream and threatening other parts of the body.

G. Treatment for Uncomplicated UTIs

UTIs in low-risk women can often be successfully treated over the phone. In such cases, a health
professional provides the patients with 3-day antibiotic regimens without even requiring an office urine
test. This course is recommended only for women at low risk for recurrent infection, who do not have
symptoms (such as vaginitis) suggesting other problems.

Antibiotic Regimen. Oral antibiotic treatment cures 94% of uncomplicated urinary tract infections,
although the rate of recurrence remains high. The following antibiotics are commonly used for
uncomplicated UTIs:

 The standard regimen has traditionally been a 3-day course of trimethoprim-sulfamethoxazole,

commonly called TMP-SMX (Bactrim, Cotrim, Septra). TMP-SMX combines an antibiotic with a sulfa
drug. A single dose of TMP-SMX is sometimes prescribed in mild cases, but cure rates are generally
lower than with 3-day regimens.
 Fluoroquinolone antibiotics, also called quinolones, have usually been a second choice. However,
in geographic areas that have a high resistance to TMP-SMX, quinolones are now the first-line
treatment for UTIs. Ciprofloxacin (Cipro) is the quinolone antibiotic most commonly prescribed.
Quinolones are usually given over a 3-day period. Pregnant women should not take these drugs.

 Nitrofurantoin (Furadantin, Macrodantin) is a third option. This drug must be given for longer
than 3 days.

 Fosfomycin (Monurol) is not as effective as other antibiotics but may be used during pregnancy.
Resistance rates to this drug are very low.

 Many other effective antibiotics are available, including amoxicillin (with or without clavulanate)
and cephalosporins. Doxycycline is often effective but cannot be given to children or pregnant
women.

After a week of antibiotic treatment, most patients are free of infection. If the symptoms do not clear up
within the first few days of therapy, doctors generally suggest that women discontinue their antibiotic
and provide a urine sample for culturing in order to identify the specific organism causing the condition.
Treatment for Relapsing Infection. A relapsing infection (caused by treatment failure) occurs within 3
weeks in about 10% of women. Relapse is treated similarly to a first infection, but the antibiotics are
usually continued for 7 - 14 days. (Relapsing infections may be due to structural abnormalities,
abscesses, or other problems that may require surgery, and such conditions should be ruled out.)

Treatment for Recurrent Infections

Women who have two or more symptomatic UTIs within 6 months or three or more over the course of a
year may need preventive antibiotics. A woman's own perception of discomfort can generally guide her
decisions on whether to use preventive antibiotics or not. All women should use lifestyle measures to
prevent recurrences.

Intermittent Self Treatment. Many, if not most, women with recurrent UTIs can effectively self-treat
recurrent UTIs without going to a doctor. In general, this requires the following steps:

 As soon as the patient develops symptoms, she takes the antibiotic. Infections that occur less
than twice a year are usually treated as if they were an initial attack, with single-dose or 3-day
antibiotic regimens.
 At that time, she also performs a clean-catch urine test and sends it to the doctor for culturing to
confirm the infection.

A woman should consult a doctor under the following circumstances:

 If symptoms have not gone away within 48 hours

 If there is a change in symptoms

 If the patient suspects that she is pregnant

 If the patient has more than four infections a year

Women who are not good candidates for self-treatment are those with impaired immune systems,
previous kidney infections, structural abnormalities of the urinary tract, or a history of infection with
antibiotic-resistant bacteria.

Postcoital Antibiotics. If recurrent infections are clearly related to sexual activity and episodes recur more
than two times within a 6-month period, a single preventive dose taken immediately after intercourse is
very effective. Antibiotics for such cases include TMP-SMX, nitrofurantoin, cephalexin, or a
fluoroquinolone (such as ciprofloxacin). (Fluoroquinolones are not appropriate during pregnancy.)

Continuous Preventive Antibiotics (Prophylaxis). Continuous preventive (prophylactic) antibiotics are an

option for some women who do not respond to other measures. With this approach, low-dose
antibiotics are taken continuously for 6 months or longer.
Typical prophylactic regimens include one dose of nitrofurantoin (50 mg), 1/2 tablet of TMP-SMX, or
cephalexin (250 mg) daily. Taking the antibiotic at bedtime may be most effective. Studies suggest that
continuous prophylactic antibiotics reduces recurrences by up to 95% and may prevent kidney infection.

Adverse effects mostly include gastrointestinal problems and yeast infections. (Taking probiotic
supplements or eating yogurt may help prevent yeast infections.) Although there is concern that
continuous risk increases the risk for bacteria that are resistant to the antibiotics, studies to date have
not reported any significant risk even up to 5 years of use.

Treatment for Kidney Infections (Pyelonephritis)

Treating Uncomplicated Kidney Infections. Patients with uncomplicated kidney infections (pyelonephritis)
may be treated at home with oral antibiotics. Such patients are healthy and nonpregnant. They typically
are experiencing fever, chills, and flank pain. However, they are not nauseous or vomiting and show no
symptoms or signs of kidney involvement or complicated infection.

The standard treatment for uncomplicated pyelonephritis is a 14-day course of oral antibiotics, usually
trimethoprim-sulfamethoxazole (TMP-SMX) or a fluoroquinolone. Sometimes patients with
uncomplicated pyelonephritis first receive an antibiotic injection.

Oral amoxicillin or amoxicillin-clavulanate (Augmentin) may be prescribed for women with bacteria
(Gram-positive organisms, including Enterococcus species and S. saprophyticus) that do not respond to
standard regimens.

A urine culture may be obtained within 1 week of completion of therapy and again 4 weeks later.

Treating Moderate-to-Severe Kidney Infections. Patients with moderate-to-severe acute kidney infection
and those with severe symptoms or other complications may need to be hospitalized. In such cases,
antibiotics are usually given intravenously for 3 - 5 days or until symptoms are relieved and patients have
not shown any signs of fever for 24 - 48 hours.

If fever and back pain continue after 72 hours of antibiotic administration, the doctor will usually order
imaging tests to see if abscesses, obstructions, or other abnormalities are present.

Treating Chronic Kidney Infections. Patients with chronic pyelonephritis are often treated with long-term
antibiotics, even during periods when they have no symptoms.

Treatments for Specific Populations

Treating Pregnant Women. Pregnant women should be screened for UTIs, since they are at high risk for
UTIs and their complications. The antibiotics used during pregnancy include amoxicillin, ampicillin,
nitrofurantoin, and cephalosporin. Fosfomycin (Monurol) is not as effective as others but may be used
during pregnancy. Pregnant women should not take fluoroquinolones.
Pregnant women with asymptomatic bacteriuria (evidence of infection but no symptoms) have a 30%
risk for acute pyelonephritis in their second or third trimester. They need screening and treatment for
this condition. In such cases, they should be treated with a short course of antibiotics (3 - 5 days). For an
uncomplicated UTI, pregnant women may need longer-term antibiotics (7 - 10 days).

Treating Patients with Diabetes. Women with diabetes have more frequent and more severe UTIs than
women without the disease. Many doctors recommend that patients with diabetes and UTI, even an
uncomplicated infection, be treated with antibiotics for 7 - 14 days.

Treating Urethritis in Men. Urethritis in men has typically been treated with a 7-day regimen of
doxycycline. Some research suggests that a single dose of azithromycin may be just as effective while
causing fewer side effects. One-dose treatment also improves compliance, so cure rates may even be
better than with a long-term regimen. However, once an infection spreads to the prostate gland it is
harder to treat, so most doctors still prefer the longer regimen. Patients with urethritis should also be
tested for an accompanying sexually transmitted disease such as gonorrhea.

Treating Children with UTIs. Children with UTIs are generally treated with TMP-SMX or cephalexin
(Keflex). These drugs are usually taken by mouth in either liquid or pill form. Doctors sometimes give
them as a shot or IV. Children usually respond to treatment within a few days. Antibiotic resistance to
cephalosporin antibiotics such as cephalexin is increasing, and some doctors prefer to prescribe an
aminoglycoside antibiotic. Gentamicin (Garamycin) is the aminoglycoside antibiotic that is most
commonly used. It is given intravenously.

Vesicoureteral reflux (VUR) is a concern for children with UTIs. About a third of children with UTIs
develop this condition, in which urine backs up into the kidneys. VUR can lead to kidney infection
(pyelonephritis), which can cause kidney damage. Long-term antibiotics or surgery have traditionally
been options to correct vesicoureteral reflux (VUR) and prevent infection, but there is debate as to the
benefit of these approaches. Recent studies indicate that preventive treatment with antibiotics may not
be much help for preventing recurrent urinary tract infections in children, and that VUR itself may not
substantially increase the risk for recurrent UTIs.

Children with acute kidney infection are treated with oral cefixime (Suprax) or a short course (2 - 4 days)
of an intravenous (IV) antibiotic (typically gentamicin, given in one daily dose). An oral antibiotic then
follows the IV.

Management of Catheter-Induced Urinary Tract Infections

Catheter-induced urinary tract infections are very common, and preventive measures are extremely
important. Catheters should not be used unless absolutely necessary, and they should be removed as
soon as possible. Reducing the risk for infections during long-term catheter use, however, remains
problematic.

Intermittent Use of Catheters. If a catheter is required for long periods, it is best to use it intermittently if
possible (as opposed to an indwelling catheter). Some doctors recommend replacing it every 2 weeks to
reduce the risk of infection and irrigating the bladder with antibiotics between replacements.
Daily Hygiene. A typical catheter is one that has been preconnected and sealed and uses a drainage bag
system. To prevent infection, some of the following tips may be helpful:

 Drink plenty of fluids, including 3 glasses of cranberry juice a day.

 The catheter tube should be free of any knots or kinks.

 Clean the catheter and the area around the urethra with soap and water daily and after each
bowel movement. (Women should be sure to clean front to back.)

 Wash hands before touching the catheter or surrounding area.

 Never disconnect the catheter from the drainage bag without careful instructions from a health
professional on strict methods for preventing infection.

 Keep the drainage bag off the floor.

 Stabilize the bag against the leg using tape or some other system.

Antibiotics for Catheter-Induced Infections. Patients using catheters who develop UTIs with symptoms
should be treated for each episode with antibiotics and the catheter should be removed, if possible. A
major problem in treating catheter-related UTIs is that the organisms involved are constantly changing.
Because there are likely to be multiple species of bacteria, doctors generally recommend an antibiotic
that is effective against a wide variety of microorganisms.

Although high bacteria counts in the urine (bacteriuria) occur in most catheterized patients,
administering antibiotics to prevent a UTI is rarely recommended. Many catheterized patients do not
develop symptomatic urinary tract infections even with high bacteria counts. If bacteriuria occurs
without symptoms, antibiotic therapy has little benefit if the catheter is to remain in place for a long
period.

Catheterization is accomplished by inserting a catheter (a hollow tube, often with an

inflatable balloon tip) into the urinary bladder. This procedure is performed for urinary
obstruction, following surgical procedures to the urethra, in unconscious patients (due to
surgical anesthesia or coma), or for any other problem in which the bladder needs to be kept
empty (decompressed) and urinary flow assured. Catheterization in males is slightly more
difficult and uncomfortable than in females because of the longer urethra
H. Lifestyle Changes and Home Remedies

Although there is no evidence that good hygiene makes a real difference in preventing UTIs, it is
always a wise practice. The following are some hygiene tips:

 Clean the genital and urinary areas from front to back with soap and water after each bowel
movement.
 Keep the genital and anal areas clean before and after sex. Urinate before and after intercourse
to empty the bladder and cleanse the urethra of bacteria.
 Avoid tight-fitting pants.

 Wear cotton-crotch underwear and panty hose, changing both at least once a day. (Mild
detergents are best for washing underwear.)

 Take showers rather than baths.

 Avoid bath oils, feminine hygiene sprays, douches, and powders. As a general rule, do not use
any product containing perfumes or other possible allergens near the genital area. Douching is never
recommended. It may destroy the natural antiviral organisms normally present in the vagina, making
women more susceptible to human papillomavirus (HPV), a risk factor for cervical cancer.

 Choose sanitary napkins instead of tampons (which some doctors believe encourage infection).
Napkins and tampons, in any case, should be changed after each urination.

 Urinate frequently.

Appropriate hygiene and cleanliness of the genital area may help reduce the chances of introducing
bacteria through the urethra. Females are especially vulnerable to this, because the urethra is in close
proximity to the rectum. The genitals should be cleaned and wiped from front to back to reduce the
chance of dragging E. coli bacteria from the rectal area to the urethra.

Sexual Precautions

The following recommendations may reduce the risks from sexual activity:

 In women using contraceptives, consider alternatives, particularly if exposed to spermicides

from condoms or diaphragms. Discuss the best contraceptive choice with a doctor.
 Avoid sex with multiple partners. This can cause many health problems, including sexually
transmitted diseases and UTIs.

Fluids

Many doctors believe that emptying the bladder frequently will help prevent bladder irritation and
therefore recommend drinking plenty of water daily and urinating often.

Cranberries, Blueberries, and Lignonberries

Cranberries, blueberries, and lignonberry, a European relative of the cranberry, are three fruits that may
have protective properties against urinary tract infections. Researchers are finding that red pigments in
these closely related fruits called tannins (or proanthocyanadins) prevent E. coli bacteria from adhering
to cells in the urinary tract, thereby inhibiting infection. Fructose, which is commonly used to sweeten
fruit juices, may also interfere with bacterial adhesion.
Cranberry juice is the best-studied home remedy for UTIs. Evidence indicates that cranberry juice may
help decrease the number of symptomatic UTIs, especially for women with recurrent urinary tract
infections.

It is not clear what the optimum dosage is for cranberries, or whether it is best to use juice or tablet
form. Some research recommends drinking at least 1- 2 cups of 30% cranberry or lignonberry juice daily,
or taking at least 300 - 400 mg in tablet form twice daily.

Probiotics, Lactobacilli, and Fermented Milk Products

Probiotics are beneficial bacteria that may protect against infections in the genital and urinary tracts. The
best-known probiotics are the lactobacilli strains, such as acidophilus, which is found in yogurt and other
fermented milk products (kefir), as well as in dietary supplement capusles. The probiotics bifidobacteria
and GG lactobacilli may prove also be helpful. Other probiotics include the lactobacilli rhamnosus, casel,
plantarium, bulgaricus, and salivarius, and also Enterococcus faecium and Streptococcus thermophilus.

Lactobacilli may have the potential to help protect women from UTIs by maintaining a low pH
environment, hindering E. coli growth, and producing hydrogen peroxide, which produces an
environment hostile for bacteria. Not all studies show a benefit for probiotics in preventing urinary tract
infections. More research is needed.

I.