urinary%20tract%20infection%20in%20women%20-%20complicated
URINARY TRACT INFECTION IN WOMEN - COMPLICATED
Complicated urinary tract infection (UTI) is associated with a condition [eg structural or functional abnormalities of the genitourinary tract (GUT)] or the presence of an underlying disease that interferes with host defense mechanisms, which increases the risks of acquiring infection, failing therapy or having recurrent infections. The successful treatment of a complicated UTI considers effective antimicrobial therapy, optimal management of the underlying abnormalities or other diseases and adequate life-supporting measures.

Urinary%20tract%20infection%20in%20women%20-%20complicated Signs and Symptoms

Definition

  • Complicated urinary tract infection (UTI) is associated with a condition [eg structural or functional abnormalities of the genitourinary tract (GUT)] or the presence of an underlying disease that interferes with host defense mechanisms, which increases the risks of acquiring infection, failing therapy or having recurrent infections
  • Associated with altered microbiology that favors more antimicrobial-resistant strains that are sometimes less virulent than those found in uncomplicated UTI

Etiology

  • The spectrum of bacteria causing complicated UTI is much larger than that of uncomplicated UTI and more likely to be antibiotic-resistant
    • Escherichia coli, Proteus, Klebsiella, Pseudomonas, Serratia spp and enterococci are the usual strains found in urine culture
  • Catheter-associated UTI
    • Short-term (<1 week): E coli, Pseudomonas aeruginosa
    • Long-term (>1 week): Proteus mirabilis, E coli, P aeruginosa, Providencia stuartii, Morganella morganii, Citrobacter sp, Enterobacter sp, Enterococcus sp, Candida spp
  • Diabetes mellitus (DM) patients: E coli, Klebsiella pneumoniae, P mirabilis, P aeruginosa, Enterobacter sp, Enterococcus sp, Candida spp
  • Renal transplant patients: E coli, P mirabilis, K pneumoniae, P aeruginosa, Gram-positive cocci, Enterobacter sp, Enterococci sp, Serratia sp, Acinetobacter sp, Citrobacter spp, Corynebacterium urealyticum
  • Neutropenic patients: Gram-negative bacilli especially P aeruginosa, Staphylococcus aureus, Candida sp 
  • Patients with anatomic abnormalities: E coli, K pneumoniae, P aeruginosa, P mirabilis

Signs and Symptoms

  • A complicated UTI does not necessarily present with clinical symptoms
  • Dysuria, urgency, frequency, flank pain, costovertebral angle tenderness, suprapubic pain and fever may or may not be present
  • May present with signs of sepsis: Hypotension, temperature >40°C, tender subcostal or intractable nausea and vomiting
  • Symptoms may vary from severe obstructive acute pyelonephritis with imminent urosepsis to a catheter-associated post-operative UTI
  • Concomitant medical conditions (DM, renal failure) are often present

Risk Factors

Factors that Suggest a Potential Complicated UTI:

  • >7 days of symptoms prior to presentation
  • Azotemia due to intrinsic renal disease
  • Chemical or radiation injuries of the uroepithelium
  • Comorbidities that predispose to papillary necrosis (eg sickle cell disease, severe DM, analgesic abuse, Pseudomonas sp infection]
  • Elderly
  • Pregnancy
  • Healthcare-associated or hospital-acquired infection
  • Immunosuppression
  • Incomplete bladder emptying with >100 mL of residual urine
  • Obstructive uropathy (eg bladder outlet obstruction, calculi, stones, stricture, tumor)
  • Peri- and postoperative UTI
  • Presence of an indwelling urinary catheter or use of intermittent bladder catheterization
  • Recent antimicrobial use
  • Recent urinary tract intervention or instrumentation
  • Renal insufficiency and transplantation
  • Unresolved UTI due to failed response to antibiotic therapy
  • Urinary tract modifications (eg ileal loop or pouch)
  • Vesicoureteral reflux or other functional abnormalities
  • Residence in an institution providing extended care
  • Foreign body 
  • Isolated extended-spectrum beta-lactamase (ESBL)-producing or multidrug-resistant organisms
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