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Indications for imaging in patient with UTI, from Campbell's

Causes for bacterial persistence in UTIs, from Campbell's

UTI surveillance in high risk patients, from Campbell's

UTI Evaluation

Presenting symptoms

• Common: frequency, urgency, dysuria, suprapubic pain, fever
• Hematuria: can occur with UTI, check UA
• Pneumaturia/fecaluria: high suspicion for fistula
• Differential: pelvic floor dysfunction, STI, reflux, vaginitis/urethritis

Collecting a good urine sample

1. Obtain clean catch (0 squamous cells is best sample)
2. If tube (foley/PCN) present, consider exchanging tube (if possible) prior to collecting sample
3. If ostomy, catheterize stoma for collection
4. Do not collect from foley/PCN bag!

Lab Findings

• Leukocyte esterase: sensitive but not specific for UTI
• Nitrites: produced by Enterobacteriaceae, also seen with pyridium
• Cloudy urine: pyuria or precipitated phosphate crystals in alkaline/concentrated urine
• Microscopic UA: presence of bacteruria most indicative
• Mycoplasma/Ureaplasma: appear to be colonizers, unrelated to UTI symptoms, testing not beneficial (per Souders et al JU 2021)

Confounding factors

Asymptomatic Bacteruria

• Definition: bacteria in urine in the absence of any symptoms
• Prevalence: 1-5% healthy young women, 20% women older than 80
• Catheters: 23-89% patients using CIC vs 100% patients with longterm catheter usage
• Screen/treat if: pregnant (increased risk for complications) or undergoing GU instrumentation (increased risk for bacteruria/sepsis)
• Do not screen/treat even if: diabetic, SCI, foreign body in GU tract, prior to non-urologic surgery - no overall benefit and increases risk for resistant organisms

Spinal Cord Injury Patients

• Common UTI symptoms: usually do not have classic symptoms, may show fatigue, fever, vague abdominal/back pain, spasticity, autonomic dysreflexia, new/worsening incontinence
• Recurrent infections: evaluate with upper tract imaging (assess for stones) and urodynamics (high-risk bladder)
• Do not screen or treat asymptomatic bacteruria in patients with SCI and indwelling catheters
• Antibiotic prophylaxis and irrigation have not been shown to decrease bacteruria
• Consider treatment when urease organisms present, may increase risk for bladder stones and catheter encrustation)