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

• 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

• 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

• 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

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