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URINARY TRACT INFECTION - COMPLICATED
Urinary tract infection (UTI) is complicated if the UTI is associated with factors that increases colonization and decreases therapy efficacy. Factors may include one or all of the following: Structural or functional abnormalities of the genitourinary tract; presence of an underlying disease that interferes with host defense mechanisms or the patient being immunocompromised; and being infected by a multi-drug resistant bacteria.
Principles of therapy includes effective antimicrobial antimicrobial therapy, optimal management of the underlying abnormalities or other diseases & adequate life-supporting measures.

Diagnosis

  • Urine specimen for culture should be obtained prior to the administration of antibiotics
    • Selection of antibiotic should be re-evaluated once culture results become available
  • If possible, to avoid the emergence of resistant strains, therapy should be guided by urine culture

History

  • Specific questioning for the presence or absence of prior urinary infections & therapy, genitourinary surgeries, nephrolithiasis, gross hematuria, sickle cell disease & other associated disease predispositions

Laboratory Tests

  • Urine analysis w/ microscopic exam, urine culture & sensitivity testing should be performed before, during & after therapy
Significant Bacteriuria
  • Women: ≥105 colony forming units (cfu)/mL in midstream urine (MSU) sample or >104 cfu/mL in straight catheter urine sample
  • Men: ≥104 cfu/mL in MSU or straight catheter urine sample
  • Asymptomatic patients: 2 consecutive urine samples showing ≥105 cfu/mL taken at least 24 hours apart w/ the same bacterial species
Pyuria
  • ≥10 WBC/mm3
Dipstick Method
  • For routine assessment including leukocyte esterase test, hemoglobin & nitrite reaction

Imaging

  • Radiologic studies are indicated to find the cause of complicated urinary tract infection (UTI)
  • Imaging of the urinary tract should be undertaken to evaluate for hydronephrosis, stone disease & urinary tract abnormalities
    • Plain abdominal radiographs may be useful to evaluate for abnormal calcifications, renal contour & gas patterns
    • Intravenous (IV) pyelogram for radiographic images of the bladder, kidneys & ureters to determine extent of urinary obstruction
    • Voiding cystourethrogram for evaluation of the neurogenic bladder & urethral diverticulum, & to determine the presence of vesicoureteral reflux
    • Renal ultrasonography is an extremely valuable tool to evaluate for hydronephrosis, pyonephrosis & perirenal abscesses
    • Computed tomography (CT) scan is more sensitive for nephrolithiasis, defining renal & suprarenal pathology
    • Cystoscopy for a convenient inspection of the urethra & the bladder
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