Urinary Tract Infections (UTIs)

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

Collecting the Sample

Lab Findings

Defining Asymptomatic Bacteruria

Spinal Cord Injury Patients

Oral Antibiotics for Outpatient UTIs

Antibiotic Normal Dosing Side Effects Tips
Nitrofurantoin (Macrobid) 100mg BID GI effects
Peripheral neuropathy
Hemolysis if G6PD
Pulmonary hypersensitivity reaction (rare)
Only works well for GU infections (not tissue)
Don't give if GFR < 50 (inadequte excretion)
Caution in elderly patients
Do not take with quinolones, Mg, or probenecid
Trimethoprim-Sulfamethoxazole (Bactrim) Double-Strength (800/160mg) BID Rashes
GI effects
Hyperkalemia
Stevens Johnson syndrome (rare)
Avoid in pregnancy
Can exacerbate effects of warfarin
Fosfomycin 3g sachet x1 Headache
GI effects
Vaginitis
Not used frequently in US due to cost ($70-90)
Ciprofloxacin (Cipro) 500mg BID GI effects, dizziness, photosensitivity
CNS effects
Tendon rupture
Avoid in children or pregnancy
Decreased oral absorption with iron, zinc, or antacid (separate by 2hrs)
Can lower seizure threshold
Levofloxacin (Levaquin) 250mg BID or 750mg daily
Cefuroxime Diarrhea
Rash
Elevated LFTs
Do not use if patient has prior immediate hypersensitivity to penicillins
Use with caution if delayed hypersensitivity to penicillins
Cefoxitin
Ampicillin (w/ Sulbactam) 875/125mg BID Hypersensitivity rash
Diarrhea
Rash more likely when viral disease present

Antibiotic Coverage

Streptococcus MRSA Staph saprophyticus Enterococcus E coli Other GNRs Pseudomonas Anaerobes
Macrobid
Urinary pathogens only
No No Yes Yes Yes Yes No No
Bactrim Yes Yes Yes No Yes Yes No Yes
Levaquin/Cipro No No No No Yes Yes Yes No
Zosyn/Augmentin Yes No Yes Yes Yes Yes No Yes
1st gen Ceph
Cefazolin/Cephalexin
Yes No Yes Yes Yes Yes No No
2nd gen Ceph
Cefuroxime/Cefoxitin
Yes No Yes Yes Yes Yes No Yes
3rd gen Ceph
Ceftriaxone/Cefpodoxime
Yes No Yes Yes Yes Yes Yes (Ceftazidime only) No
4th gen Ceph
Cefepime
No No No No Yes Yes Yes No
5th gen Ceph
Ceftaroline
No Yes No No Yes Yes No No
Carbapenems Yes Yes Yes No Yes Yes Yes No
Aminoglycosides No No No No Yes Yes Yes No
Vancomycin Yes Yes Yes Yes (except VRE) No No No No
Linezolid Yes Yes Yes Yes (including VRE) No No No No
Fosfomycin Yes Yes Yes Yes Yes Yes Yes No

Cystitis

Tips for diagnosis/management

Factors indicating complicated cystitis

Emphysematous cystitis

Renal Infections

Acute Pyelonephritis

Pyelonephritis management, from Campbell's

Emphysematous Pyelonephritis

Acute Focal/Multifocal Bacterial Nephritis

Renal Abscess

Infected Hydronephrosis +/- Pyonephrosis

Perinephric abscess

Chronic pyelonephritis

Xanthogranulomatous pyelonephritis (XGP kidney)

Sexually transmitted and other genital infections

Male Urethritis

Disease Diagnosis Treatment Follow-Up
Gonorrhea Urine NAAT Ceftriaxone 250mg IM x1 + Azithromycin 1g PO x1
Substitute gemifloxacin 320mg PO x1 or gentamicin 240mg IM x1 if cephalosporins contraindicated
Abstain from sexual contact x7 days
Repeat test in 3-4mo
Test prior partners within past 60 days
Chlamydia Azithromycin 1g PO x1
Doxycycline 100mg PO BID x7 days
Erythromycin 500mg PO QID x7 days
Levofloxacin 500mg PO daily x7 days
Ofloxacin 300mg PO BID x7 days
Mycoplasma Difficult to diagnosis
Suspect if persistent/recurrent urethritis
Azithromycin 1g PO
If fails, moxifloxacin 400mg daily x7-14 days
Abstain from sex until symptoms resolve and treatment completed
test prior partners within past 60 days

Genital Ulcers

Disease # Ulcers Painful? Lymphadenopathy? Diagnosis Treatment
Syphilis
Treponema pallidum
Single No Regional Nontreponemal (sensitive): VDRL, RPR
Treponemal (specific): FTA-ABS, EIAs
Benzathine penicillin G 2.4 million U IM x1
Doxycycline 100mg PO BID x14 days
Tetracycline 500mg PO QID x14 days
Other treatments for tertiary syphilis
Herpes
HSV
Multiple Yes Painful bilateral Cell culture + PCR (swab ulcer base) Acyclovir 400mg PO TID x7-10 days
Acyclovir 200mg PO x5 x7-10 days
Valacyclovir 1g PO BID x7-10 days
Famciclovir 250mg PO TID x7-10 days
Other regimens for recurrent episodes
Chancroid
Haemophilus ducreyi
Multiple, raw Yes Unilateral and painful (50%)
may become fluctuant and rupture
1+ painful genital ulcers + typical chancroid appearance + negative syphilis and HSV tests Azithromycin 1g PO x1
Ceftriaxone 250mg IM x1
Ciprofloxacin 500mg PO BID x3 days
Erythromycin 500mg PO TID x7 days
Granuloma inguinale
Klebsiella granulomatosis
Multiple, friable No None Send-out test Azithromycin 1g PO qWeek
500mg PO qDay x3 weeks
Consider biopsy if no resolution
Lymphgranuloma Venereum
C. trachomatis serovars L1-3
Single No Painful and unilateral NAAT available Doxycycline 100mg PO BID x21 days
Erythromycin 500mg PO QID x21 days
Molluscum contagiosum
MCV
Multiple No No Based on clinical picture Observation
Avoid auto-inoculation
Local therapies

Human papillomavirus(HPV)

Human immunodeficiency virus

Fournier gangrene

Other genital infections

Vaginitis

Diagnosis Discharge pH Microscopy Symptoms Treatment Treat partner?
Normal discharge White, thick, smooth ≤ 4.5 Lactobacilli - - -
Candidiasis (C. albicans) White, thick, curdlike Mycelia Itching, dysuria Topical therapies
Fluconazole 150mg PO x1
Persistent/recurrent infections may require alternate treatments for non-C. albicans
No
Trichomoniasis Frothy, purulent ≥ 4.5 Trichomonads, WBC, amine odor Vulvar erythema/edema Metronidazole 2g PO x1
Tinidazole 2g PO x1
Yes
Bacterial vaginosis Thin, white Absent lactobacilli, clue cells, amine odor Increased discharge, odor Metronidazole 500mg PO BID x7 days
Metronidazole gel 0.75% intravaginally daily x5 days
Clindamycin 2% cream intravaginally QHS x7 days
No

Tuberculosis

Epidemiology

GU TB Spread

Manifestations

Diagnosis

First Line Therapies

Drug Dosing Side effects
Isoniazid 5mg/kg (300mg) daily
15mg/kg (900mg) 3x weekly
Hepatotoxicity
Peripheral neuropathy
Rifampin 10mg/kg (600mg) daily
10mg/kg (600mg) 3x weekly
Hepatotoxicity
Pruritis
Flulike symptoms
Pyrazinamide
(weight-based dosing)
1000-2000mg daily
1500-3000mg 3x weekly
Arthralgia
Hepatotoxicity
Pruritus/Rash
GI Symptoms
Hyperuricemia
Ethambutol
(weight-based dosing)
800-1600mg daily
1200-2400mg 3x weekly
Decreased visual acuity
Red/green color changes
Optic neuritis

Treatment tips

Surgical management

Parasitic GU infections

Schistosomiasis (Schistosoma haematobium)

Lymphatic filariasis (LF)

Other parasitic infections

References