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Urinary Tract lnfections TABLE 16. Uncommon and Emerging Tick-borne Pathogens in Humans in the United States Vector Pathogen Region Disease or Clinical Findings CIues to Diagnosis Deertick (lxodes Borrelia Lyme endemic Similar to anaplasmosis Acute illness species) miyamotoi regions Sepsis-like presentation Borrelia mayonii Upper midwest Lyme disease Possible presence of gastroi ntesti na I sym ptoms Ehrlichia muris Upper midwest Ehrlichiosis Rash uncommon eauclairensis Less severethan E. chaffeensis Powassan virus Great Lakes, Nonspecific febrile il ness I Fever, headache; encephalitis, Northeastern United meningitis States

Powassan virus Great Lakes, Nonspecific febrile il ness I Fever, headache; encephalitis, Northeastern United meningitis States Lone Star tick and Ehrlichia ewingii Southeastern and Ehrlichiosis Morulae in neutrophils rather Gulf Coast tick Southcentral United than monocytes (Amblyomma States More common in species) immunocompromised patients Heartland virus Midwest and Southern Similar to ehrlichiosis No response to doxycycline United States Bourbon virus Midwest and Southern Similar to ehrlichiosis No response to doxycycline United States Rickettsia parkeri Southeast and mid- Spotted fever rickettsiosis Eschar at site of tick attachment Atlantic United States Multiple species Francisella No regional Tularemia Ulcer may be present at site of tularensis predominance inoculation Rocky Mountain Colorado tick Western United States Nonspecific febrile illness Biphasic illness (50%) wood tick fever virus (elevations >4000 feet Conju nctival injection above sea level) Leu kopen ia, th rom bocytopen ia

Lone Star tick and Ehrlichia ewingii Southeastern and Ehrlichiosis Morulae in neutrophils rather Gulf Coast tick Southcentral United than monocytes (Amblyomma States More common in species) immunocompromised patients Heartland virus Midwest and Southern Similar to ehrlichiosis No response to doxycycline United States Bourbon virus Midwest and Southern Similar to ehrlichiosis No response to doxycycline United States Rickettsia parkeri Southeast and mid- Spotted fever rickettsiosis Eschar at site of tick attachment Atlantic United States Multiple species Francisella No regional Tularemia Ulcer may be present at site of tularensis predominance inoculation Rocky Mountain Colorado tick Western United States Nonspecific febrile illness Biphasic illness (50%) wood tick fever virus (elevations >4000 feet Conju nctival injection above sea level) Leu kopen ia, th rom bocytopen ia Soft ticks Tick-borne Western United States Nonspecific febrile illness Recurring fevers lasting 3 days (Ornithodoros relapsing fever every 7 days species) (Borrelia species) Spirochetes may be visible on microscopy

Soft ticks Tick-borne Western United States Nonspecific febrile illness Recurring fevers lasting 3 days (Ornithodoros relapsing fever every 7 days species) (Borrelia species) Spirochetes may be visible on microscopy persons with foreign bodies (e.g., indwelling catheters or cal- Staphylococcus aureus isolation in the urine may be related to culi), kidney disease, immunocompromise, obstruction, uri- instrumentation but suggests a possible hematogenous infec- nary retention from neurologic disorders, or recent antibiotic tion (i.e., an external source such as endocarditis). use are referred to as complicated. Advanced age in the pres- I( EY PO I ilTS ence of other major comorbidities or frailty may be considered o An uncomplicatedurinary tract infection refers to a complicating factor, although age alone does not define a complicated versus uncomplicated infection. A complicated infections in nonpregnant women without structural or UTI designation influences the choice and duration of antimi- neurologic abnormalities or comorbidities. crobial therapy and extent of investigation. Underestimating . Urinary tract infections in men, pregnant women, and the potential for uncomplicated UTIs to evolve into clinically persons with foreign bodies, kidney disease, immuno- severe disease should be avoided. compromise, obstruction, urinary retention from neu- Most infections occur by the ascending route. Ninety-five rologic disorders, or recent antibiotic use are considered percent of ascending UTIs are caused by a single bacterial spe- complicated. cies, mainly gram-negative aerobic bacilli originating from the . Designating an infection as complicoted influences the bowel. Uropathogenic Escherichia coli accounts for 75o/o to choice and duration of antimicrobial therapy and extent 95% of UTIs in women. Less common pathogens include other of investigation. Enterobacteriaceae, streptococci (particularly Streptococcus agalactiae), enterococci, and staphylococci (most often Staphylococcus saprophyticus). UTIs occurring in health care Diagnosis settings frequently involve a varied group of organisms (such Diagnosis is based on numerous clinical features, determining as Enterobacter, Prouidencia, Morganella, Citrobacter, the anatomic location of infection (lower or upper urinary S errqtia. Pseudomonos, and Cory nebacte rium ure alyt icum) . tract), and the presence of pyuria (>t0 leukocytes/pl) and

persons with foreign bodies (e.g., indwelling catheters or cal- Staphylococcus aureus isolation in the urine may be related to culi), kidney disease, immunocompromise, obstruction, uri- instrumentation but suggests a possible hematogenous infec- nary retention from neurologic disorders, or recent antibiotic tion (i.e., an external source such as endocarditis). use are referred to as complicated. Advanced age in the pres- I( EY PO I ilTS ence of other major comorbidities or frailty may be considered o An uncomplicatedurinary tract infection refers to a complicating factor, although age alone does not define a complicated versus uncomplicated infection. A complicated infections in nonpregnant women without structural or UTI designation influences the choice and duration of antimi- neurologic abnormalities or comorbidities. crobial therapy and extent of investigation. Underestimating . Urinary tract infections in men, pregnant women, and the potential for uncomplicated UTIs to evolve into clinically persons with foreign bodies, kidney disease, immuno- severe disease should be avoided. compromise, obstruction, urinary retention from neu- Most infections occur by the ascending route. Ninety-five rologic disorders, or recent antibiotic use are considered percent of ascending UTIs are caused by a single bacterial spe- complicated. cies, mainly gram-negative aerobic bacilli originating from the . Designating an infection as complicoted influences the bowel. Uropathogenic Escherichia coli accounts for 75o/o to choice and duration of antimicrobial therapy and extent 95% of UTIs in women. Less common pathogens include other of investigation. Enterobacteriaceae, streptococci (particularly Streptococcus agalactiae), enterococci, and staphylococci (most often Staphylococcus saprophyticus). UTIs occurring in health care Diagnosis settings frequently involve a varied group of organisms (such Diagnosis is based on numerous clinical features, determining as Enterobacter, Prouidencia, Morganella, Citrobacter, the anatomic location of infection (lower or upper urinary S errqtia. Pseudomonos, and Cory nebacte rium ure alyt icum) . tract), and the presence of pyuria (>t0 leukocytes/pl) and 28

Urinary Tract lnfections bacteriuria. Pyuria can be detected by urine dipstick, which systemic signs or symptoms of infection are absent. The preva- relies on the presence of leukocyte esterase. Although the sen- lence of ASB ranges froml"L to 5% in healthy premenopausal sitivity and specificity of dipstick testing are high (about 75,2, women (Z%-tO7 in pregnant women) to nearly 100,/. in and 85%, respectively), pyuria may result from disorders other patients with long-term indwelling urinary catheters. than infection. Leukocyte casts support a diagnosis of pyelone Accompanying pyuria is not an indication for antimicro- phritis. Microscopic or gross hematuria may occur with a UTI bial treatment. Reflex cultures (based on the detection of more but may also be seen with nephrolithiasis and tumors. A posi- than 10 leukocytes per high-powered field) in asymptomatic tive nitrite test result signifies the presence of gram-negative patients or in patients presenting with signs or symptoms bacteria capable of converting nitrates into nitrites. unrelated to the urinary system should be avoided. Treatment Quantitative cultures of a midstream, clean-void urine of ASB neither decreases the fiequency of symptomatic infec sample are the most accurate way to demonstrate bacteriuria tions nor improves other outcomes. Inappropriate treatment is in patients with suspected UTI. Because of predictable micro a major driver of antimicrobial resistance, particularly in biologz and short treatment courses, culture is not recom health care facilities. mended in women with uncomplicated cystitis. Urine cultures However, treatment is indicated in pregnant women and are indicated in pyelonephritis, complicated cystitis, and in patients undergoing an invasive procedure involving the recurrent UTIs; in patients with histories of multiple antibiotic urinary tract (Table 17). allergies; and in patients with a suspected resistant organism t(EY P0t1{It (recent antibiotic treatment, health care-associated infection, and previous multidrug-resistant UTI). The growth of 10s . Pyuria accompanying asymptomatic bacteriuria is not HVC

bacteriuria. Pyuria can be detected by urine dipstick, which systemic signs or symptoms of infection are absent. The preva- relies on the presence of leukocyte esterase. Although the sen- lence of ASB ranges froml"L to 5% in healthy premenopausal sitivity and specificity of dipstick testing are high (about 75,2, women (Z%-tO7 in pregnant women) to nearly 100,/. in and 85%, respectively), pyuria may result from disorders other patients with long-term indwelling urinary catheters. than infection. Leukocyte casts support a diagnosis of pyelone Accompanying pyuria is not an indication for antimicro- phritis. Microscopic or gross hematuria may occur with a UTI bial treatment. Reflex cultures (based on the detection of more but may also be seen with nephrolithiasis and tumors. A posi- than 10 leukocytes per high-powered field) in asymptomatic tive nitrite test result signifies the presence of gram-negative patients or in patients presenting with signs or symptoms bacteria capable of converting nitrates into nitrites. unrelated to the urinary system should be avoided. Treatment Quantitative cultures of a midstream, clean-void urine of ASB neither decreases the fiequency of symptomatic infec sample are the most accurate way to demonstrate bacteriuria tions nor improves other outcomes. Inappropriate treatment is in patients with suspected UTI. Because of predictable micro a major driver of antimicrobial resistance, particularly in biologz and short treatment courses, culture is not recom health care facilities. mended in women with uncomplicated cystitis. Urine cultures However, treatment is indicated in pregnant women and are indicated in pyelonephritis, complicated cystitis, and in patients undergoing an invasive procedure involving the recurrent UTIs; in patients with histories of multiple antibiotic urinary tract (Table 17). allergies; and in patients with a suspected resistant organism t(EY P0t1{It (recent antibiotic treatment, health care-associated infection, and previous multidrug-resistant UTI). The growth of 10s . Pyuria accompanying asymptomatic bacteriuria is not HVC colony-forming units (CFU)/mL of urine is considered signifi- an indication for urine culture or antimicrobial treat- cant bacteriuria; however, lower CFU counts support a diag- ment. nosis in those with symptoms. o Treatment of asymptomatic bacteriuria is indicated in In most adults, imaging studies are not required, but they pregnant women and in patients scheduled to undergo may be indicated when the diagnosis is unclear, when a struc- an invasive procedure involving the urinary tract. tural abnormali[z or complication is suspected, or in patients with severe illness, immunocompromise, or lack of response Cystitis to appropriate therapy. Ultrasonography can detect obstruc- Without treatment, uncomplicated cystitis (urinary frequency tion. whereas noncontrast helical CT is recommended for vis and urgency, dysuria, and suprapubic discomfort) resolves in ualizing kidney stones. Although less sensitive than CT, kidney up to 50%, of women within 1 week. Recommended first-line ultrasonography is less expensive, has no radiation exposure, antibiotic regimens should consider increased rates of E. coli and can be used in pregnant women or if CT is unavailable. antimicrobial resistance, the efficacy and advantages of short- Contrast-enhanced CT (CT urography) is recommended when course therapies, and the potential adverse effects. Preferred intrarenal or perinephric abscess is suspected. agents include nitrofurantoin (S days), trimethoprim- sulfamethoxazole (g days), and fosfomycin (1dose, but expen t( EY P0 t 1{TS sive and possibly less effective). HVC o Urine culture is not recommended in women with In geographic areas where trimethoprim- sulfamethoxazole uncomplicated cystitis but is indicated in pyelonephri- resistance exceeds 20'lo, an alternative agent should be tis, complicated cystitis, recurrent urinary tract infec- selected. The FDA indicates that fluoroquinolones should be tions, patients with multiple antibiotic allergies, and in reserved for other serious bacterial infections; however, fluo- patients with a suspected resistant organism. roquinolones (g days) and B lactam agents (including amoxi- HVC . In most adults with urinary tract infection, imaging cillin-clavulanate, cefdinir, cefaclor, and cefpodoxime-proxetil, studies are not required but may be indicated when the each 3-7 days) are considered acceptable alternative second diagnosis is unclear; when a structural abnormality or line therapies. p-Lactams are not preferred if other recom- complication is suspected; or in patients with severe i11- mended agents are available because they are less effective in ness, immunocompromise, or lack of response to eradicating infection. During pregnancy, the safest antibiotics appropriate therapy. are amoxicillin-clavulanate, cephalosporins, and nitrofuran- toin (avoid in first trimester and near term); fluoroquinolones are contraindicated, and trimethoprim-sulfamethoxazole can Management only be used safely during the second trimester. Extended- Asymptomatic Bacteriuria spectrum B-lactamase-producing Enterobacteriaceae causing Asymptomatic bacteriuria (ASB) is defined as the presence of cystitis have increased in frequency, especially with recent at least 10s CFU/mL of a uropathogen from two consecutive antimicrobial or health care-facility exposure. Because of the voided urine specimens in women or one specimen in men, or greater risk of resistant and polymicrobial infections, urine more than 102 CFUimL of one pathogen from a catheterized culture and susceptibility testing are indicated in all patients urine specimen in women or men. In all cases, local or with complicated cystitis. Fluoroquinolones are the preferred

colony-forming units (CFU)/mL of urine is considered signifi- an indication for urine culture or antimicrobial treat- cant bacteriuria; however, lower CFU counts support a diag- ment. nosis in those with symptoms. o Treatment of asymptomatic bacteriuria is indicated in In most adults, imaging studies are not required, but they pregnant women and in patients scheduled to undergo may be indicated when the diagnosis is unclear, when a struc- an invasive procedure involving the urinary tract. tural abnormali[z or complication is suspected, or in patients with severe illness, immunocompromise, or lack of response Cystitis to appropriate therapy. Ultrasonography can detect obstruc- Without treatment, uncomplicated cystitis (urinary frequency tion. whereas noncontrast helical CT is recommended for vis and urgency, dysuria, and suprapubic discomfort) resolves in ualizing kidney stones. Although less sensitive than CT, kidney up to 50%, of women within 1 week. Recommended first-line ultrasonography is less expensive, has no radiation exposure, antibiotic regimens should consider increased rates of E. coli and can be used in pregnant women or if CT is unavailable. antimicrobial resistance, the efficacy and advantages of short- Contrast-enhanced CT (CT urography) is recommended when course therapies, and the potential adverse effects. Preferred intrarenal or perinephric abscess is suspected. agents include nitrofurantoin (S days), trimethoprim- sulfamethoxazole (g days), and fosfomycin (1dose, but expen t( EY P0 t 1{TS sive and possibly less effective). HVC o Urine culture is not recommended in women with In geographic areas where trimethoprim- sulfamethoxazole uncomplicated cystitis but is indicated in pyelonephri- resistance exceeds 20'lo, an alternative agent should be tis, complicated cystitis, recurrent urinary tract infec- selected. The FDA indicates that fluoroquinolones should be tions, patients with multiple antibiotic allergies, and in reserved for other serious bacterial infections; however, fluo- patients with a suspected resistant organism. roquinolones (g days) and B lactam agents (including amoxi- HVC . In most adults with urinary tract infection, imaging cillin-clavulanate, cefdinir, cefaclor, and cefpodoxime-proxetil, studies are not required but may be indicated when the each 3-7 days) are considered acceptable alternative second diagnosis is unclear; when a structural abnormality or line therapies. p-Lactams are not preferred if other recom- complication is suspected; or in patients with severe i11- mended agents are available because they are less effective in ness, immunocompromise, or lack of response to eradicating infection. During pregnancy, the safest antibiotics appropriate therapy. are amoxicillin-clavulanate, cephalosporins, and nitrofuran- toin (avoid in first trimester and near term); fluoroquinolones are contraindicated, and trimethoprim-sulfamethoxazole can Management only be used safely during the second trimester. Extended- Asymptomatic Bacteriuria spectrum B-lactamase-producing Enterobacteriaceae causing Asymptomatic bacteriuria (ASB) is defined as the presence of cystitis have increased in frequency, especially with recent at least 10s CFU/mL of a uropathogen from two consecutive antimicrobial or health care-facility exposure. Because of the voided urine specimens in women or one specimen in men, or greater risk of resistant and polymicrobial infections, urine more than 102 CFUimL of one pathogen from a catheterized culture and susceptibility testing are indicated in all patients urine specimen in women or men. In all cases, local or with complicated cystitis. Fluoroquinolones are the preferred 29

Urinary Tract lnfections TA9LE 17. Asymptomatic Baeteriuria Screening and Treatment lnappropriate Screening and Treatment for Appropriate Screening and Treatment lnsufficient Evidence for Patients or Conditions for Patients or Conditions Recommendation Healthy nonpregnant women of all ages Pregnant womenu High-risk neutropenia' Older, com m u n ity-l ivi n g, fu nctiona ly i m pai red ad u lts I Endoscopic urologic procedures with Removal of indwelling bladder mucosal bleedingb catheter Older adults in long-term care facilities Older, fu nctiona lylcog n itively i m pai red ad u lts with I delirium in the absence of genitourinary symptoms or signs of infection Older, fu nctiona lylcog n itively i m pa i red ad u lts who I experience a fall in the absence of genitourinary symptoms or signs of infection Diabetes Kidney transplants (30 days or more after surgery) Nonkidney solid organ transplants Spinal cord injury Short-term (<30 d ays) i ndwel I i n g u reth ra I catheters Long-term i ndwelli ng catheters Elective nonurologic surgery Artificial urine sphincter or penile prosthesis surgeries lmplanted urologic devices "lnsufficient evidence to recommend repeat screening and treatment. bTransurethral resection o{ the prostate or procedure during which mucosal bleeding is anticipated. 'Absolute neutrophil count <100/pL (0.1 x 10elL), >7 days duration.

experience a fall in the absence of genitourinary symptoms or signs of infection Diabetes Kidney transplants (30 days or more after surgery) Nonkidney solid organ transplants Spinal cord injury Short-term (<30 d ays) i ndwel I i n g u reth ra I catheters Long-term i ndwelli ng catheters Elective nonurologic surgery Artificial urine sphincter or penile prosthesis surgeries lmplanted urologic devices "lnsufficient evidence to recommend repeat screening and treatment. bTransurethral resection o{ the prostate or procedure during which mucosal bleeding is anticipated. 'Absolute neutrophil count <100/pL (0.1 x 10elL), >7 days duration. choice pending results, although fosfomycin, nitrofurantoin, (ciprofloxacin for 7 days or levofloxacin for 5 days for uncom and B-lactams are reasonable options. Trimethoprim- plicated infections; lO-14 days for complicated infections) are sulfamethoxazole is used for specific susceptible pathogens. the only oral agents recommended for empiric outpatient The recommended treatment duration is 7 to 10 days rather treatment, but an initial dose of a long-acting parenteral anti- than a 3 day regimen but is less well defined. Other than in biotic (such as ceftriaxone, 1 g, or a once-daily aminoglyco- pregnant women. test of cure is not indicated in those report- side) should replace fluoroquinolones when local resistance ing symptom resolution. rates exceed 10'2,. When a fluoroquinolone is contraindicated, trimethoprim-sulfamethoxazole twice daily for 14 days maybe I(EY POIT{T used after pathogen susceptibility is proven; trimethoprim- HVC o Preferred agents for uncomplicated cystitis include sulfamethoxazole should be avoided as initial empiric therapy nitrofurantoin (5 days), trimethoprim- sulfamethoxazole because of the high level of E. coli resistance in the community. (3 days). and fosfomycin (1 dose, but least preferred); Oral B lactams have lower efficacy with higher relapse rates fluoroquinolones should not be used as first-line therapy but may be alternatives if susceptibility results are known and in cystitis. no other options are available. Depending on the risk of antimicrobial resistance and on Acute Pyelonephritis recent antibiotic use, inpatient parenteral antimicrobial options Lower urinary tract symptoms (frequency, urgency, and dys include a fluoroquinolone, extended-spectrum cephalosporins uria) often precede the onset of fever, chills, flank pain, and at (ceftriaxone or cefepime) or extended spectmm penicillins times nausea and vomiting, which characterize acute pyelone- (piperacillin tazobactam), or a carbapenem (meropenem, imi phritis. Infection can usually be managed in the outpatient set- penem, or ertapenem). Empiric fluoroquinolones therapy is ting with oral antibiotics. Hospitalization is advised for patients avoided in severely ill patients with complicated pyelonephritis with hemodynamic instability, obstructive disease, pregnancy, because of the increasing potential for resistance. complicating comorbidities, pathogen resistance requiring par- Therapy can be completed with active oral agents when enteral antibiotic therapy, inability to tolerate oral medications, an adequate clinical response has been observed. Patients with or lack of reliable home supervision or clinical follow up. bacteremia do not require longer treatment courses and may Urine culture with susceptibility testing obtained before be converted to appropriate oral therapy when clinically initiation of empiric therapy is required. Fluoroquinolones stable.

choice pending results, although fosfomycin, nitrofurantoin, (ciprofloxacin for 7 days or levofloxacin for 5 days for uncom and B-lactams are reasonable options. Trimethoprim- plicated infections; lO-14 days for complicated infections) are sulfamethoxazole is used for specific susceptible pathogens. the only oral agents recommended for empiric outpatient The recommended treatment duration is 7 to 10 days rather treatment, but an initial dose of a long-acting parenteral anti- than a 3 day regimen but is less well defined. Other than in biotic (such as ceftriaxone, 1 g, or a once-daily aminoglyco- pregnant women. test of cure is not indicated in those report- side) should replace fluoroquinolones when local resistance ing symptom resolution. rates exceed 10'2,. When a fluoroquinolone is contraindicated, trimethoprim-sulfamethoxazole twice daily for 14 days maybe I(EY POIT{T used after pathogen susceptibility is proven; trimethoprim- HVC o Preferred agents for uncomplicated cystitis include sulfamethoxazole should be avoided as initial empiric therapy nitrofurantoin (5 days), trimethoprim- sulfamethoxazole because of the high level of E. coli resistance in the community. (3 days). and fosfomycin (1 dose, but least preferred); Oral B lactams have lower efficacy with higher relapse rates fluoroquinolones should not be used as first-line therapy but may be alternatives if susceptibility results are known and in cystitis. no other options are available. Depending on the risk of antimicrobial resistance and on Acute Pyelonephritis recent antibiotic use, inpatient parenteral antimicrobial options Lower urinary tract symptoms (frequency, urgency, and dys include a fluoroquinolone, extended-spectrum cephalosporins uria) often precede the onset of fever, chills, flank pain, and at (ceftriaxone or cefepime) or extended spectmm penicillins times nausea and vomiting, which characterize acute pyelone- (piperacillin tazobactam), or a carbapenem (meropenem, imi phritis. Infection can usually be managed in the outpatient set- penem, or ertapenem). Empiric fluoroquinolones therapy is ting with oral antibiotics. Hospitalization is advised for patients avoided in severely ill patients with complicated pyelonephritis with hemodynamic instability, obstructive disease, pregnancy, because of the increasing potential for resistance. complicating comorbidities, pathogen resistance requiring par- Therapy can be completed with active oral agents when enteral antibiotic therapy, inability to tolerate oral medications, an adequate clinical response has been observed. Patients with or lack of reliable home supervision or clinical follow up. bacteremia do not require longer treatment courses and may Urine culture with susceptibility testing obtained before be converted to appropriate oral therapy when clinically initiation of empiric therapy is required. Fluoroquinolones stable. 30

Urinary Tract I nfections Imaging studies are only necessary in patients with pro patients who have required treatment for cystitis or ASB to longed fever (>72 hours) or persistent bacteremia, in whom prevent recurrence during pregnancy. Approximately 507, of complications such as obstruction or perinephric and intrare patients revert to previous recurrence patterns within nal abscesses must be excluded. Routine follow-up urine cul- 6 months of prophylaxis discontinuation. Recommended daily tures are only indicated in pregnant women. low-dose prophylactic antibiotics include nitrofurantoin, I(EY POI IITS trimethoprim-sulfamethoxazole, and cephalexin. Fluoroqui- nolones are very effective but not recommended. Other HVC o Urine culture with susceptibility testing is required in options include postcoital antimicrobial prophylaxis and self acute pyelonephritis before initiation of empiric therapy; diagnosis with sel f-treatment. follow-up urine cultures are only indicated in pregnant women. I(EY POtilT5 . Ciprofloxacin for 7 days or levofloxacin for 5 days are o Reinfection is generally caused by bacteria separate recommended for uncomplicated pyelonephritis. from the original infection, presents more than 2 weeks o Avoid choosing a fluoroquinolone in severely ill patients after treatment cessation for the previous infection, and is treated with standard first-line antimicrobial agents. with complicated pyelonephritis because of the increas ing potential for resistance. . Daily prophylactic antimicrobial therapy is an option in women who have had three or more urinary tract infec- HVC o Imaging studies are only necessary in patients with pye- tions in the previous 12 months or two or more in the pre lonephritis and fever for more than72 hours, persistent vious 6 months; other options include postcoital antimi- bacteremia, or when complications are suspected. crobial prophylaxis and self-diagnosis with self-treatment.

Imaging studies are only necessary in patients with pro patients who have required treatment for cystitis or ASB to longed fever (>72 hours) or persistent bacteremia, in whom prevent recurrence during pregnancy. Approximately 507, of complications such as obstruction or perinephric and intrare patients revert to previous recurrence patterns within nal abscesses must be excluded. Routine follow-up urine cul- 6 months of prophylaxis discontinuation. Recommended daily tures are only indicated in pregnant women. low-dose prophylactic antibiotics include nitrofurantoin, I(EY POI IITS trimethoprim-sulfamethoxazole, and cephalexin. Fluoroqui- nolones are very effective but not recommended. Other HVC o Urine culture with susceptibility testing is required in options include postcoital antimicrobial prophylaxis and self acute pyelonephritis before initiation of empiric therapy; diagnosis with sel f-treatment. follow-up urine cultures are only indicated in pregnant women. I(EY POtilT5 . Ciprofloxacin for 7 days or levofloxacin for 5 days are o Reinfection is generally caused by bacteria separate recommended for uncomplicated pyelonephritis. from the original infection, presents more than 2 weeks o Avoid choosing a fluoroquinolone in severely ill patients after treatment cessation for the previous infection, and is treated with standard first-line antimicrobial agents. with complicated pyelonephritis because of the increas ing potential for resistance. . Daily prophylactic antimicrobial therapy is an option in women who have had three or more urinary tract infec- HVC o Imaging studies are only necessary in patients with pye- tions in the previous 12 months or two or more in the pre lonephritis and fever for more than72 hours, persistent vious 6 months; other options include postcoital antimi- bacteremia, or when complications are suspected. crobial prophylaxis and self-diagnosis with self-treatment. Recurrent UrinaryTract lnfections in Women An estimated 25'/o to 30% of patients experience a second Acute Bacterial Prostatitis infection within 6 months of their first UTI. Relapsed infec, Benign prostatic hyperplasia resulting in urinary obstruction tions are those recurring with the same organism (determined and altered urine flow is the most common reason for the by repeat culture)within 2 weeks of completing antimicrobial increased incidence of UTIs in men older than 60 years. therapy (51o-lo7o of cases). Relapse suggests infection with a Other risk factors include unprotected sexual intercourse, resistant bacterium, incomplete treatment, or a structural chronic indwelling urinary catheters, and transrectal pros abnormality, including renal calculi. Relapsed infection tate biopsy. Approximately 5'l. of men develop chronic pros requires a urine culture. Reinfection, the most common type tatitis after acute infection and up to 10% develop a prostatic of recurrent UTI, is generally caused by a bacterial strain sepa- abscess. rate from the original infection and presents more than Presenting symptoms include sudden fever, pelvic or per- 2 weeks after treatment cessation for the previous infection. ineal pain, urinary frequency and dysuria, and increasing Assuming the organism is sensitive, patients r,t ith relapsed obstructive symptoms. Acute bacterial prostatitis frequently infection are treated for a presumed upper UTI for 7 to 10 days presents as a severe systemic infection, with bacteremia occur with the same antibiotic as initially prescribed or, if bacterial ring in approximately 25"/. of patients. Cautious digital rectal resistance is discovered, an alternative agent. Likewise, the examination of the prostate reveals a boggz and tender gland. same first-line antimicrobial agent can be given for reinfec Urinalysis and culture are required to confirm the diagnosis. tions, although an alternative antibiotic should be used if the Although pyuria may occur for reasons other than infection, recurrence occurs within 6 months, particularly if the original its absence strongly indicates no infection. Prostate-specific agent was trimethoprim-sulfamethoxazole, because of the antigen tests should be avoided because results may be ele- increased chance of resistance. Cystoscopy and imaging stud- vated because of inflammation of the gland. ies are indicated only when structural abnormalities or Hospitalized patients and those with severe infection obstruction are potential risk factors. require blood cultures. Gram negative uropathogens account Strategies to prevent infection recurrence include antimi- for about B0% of infections, two thirds of which are E. coli; crobial and nonantimicrobial interventions, such as spermi- Proteus, Enterobacter, Serratia, Klebsiello, and sometimes cide contraceptive avoidance and topical vaginal estrogen Pseudomonos and enterococcal species compose most of the use in postmenopausal women without contraindications. other pathogens. In men 35 years or younger. sexually trans Cranberry products have not been proven effective in con- mitted infections, including Neisserio gonorrhoeoe and trolled trials. Prophylactic daily antimicrobial agents have Chlamydia trachomotis, must be considered. been found to reduce the risk of recurrences by nearly 957,; Fluoroquinolone antibiotics (ciprofloxacin, levofloxa- they are an option in women who have had three or more UTIs cin) may be the preferred oral agents for treating acute in the previous 12 months, or two or more in the previous bacterial prostatitis but should not be used if recent geni- 6 months, and have received no benefit from other prevention tourinary instrumentation was performed because most efforts. Prophylactic therapy may be considered in pregnant E. coli strains are now resistant to fluoroquinolones.

Recurrent UrinaryTract lnfections in Women An estimated 25'/o to 30% of patients experience a second Acute Bacterial Prostatitis infection within 6 months of their first UTI. Relapsed infec, Benign prostatic hyperplasia resulting in urinary obstruction tions are those recurring with the same organism (determined and altered urine flow is the most common reason for the by repeat culture)within 2 weeks of completing antimicrobial increased incidence of UTIs in men older than 60 years. therapy (51o-lo7o of cases). Relapse suggests infection with a Other risk factors include unprotected sexual intercourse, resistant bacterium, incomplete treatment, or a structural chronic indwelling urinary catheters, and transrectal pros abnormality, including renal calculi. Relapsed infection tate biopsy. Approximately 5'l. of men develop chronic pros requires a urine culture. Reinfection, the most common type tatitis after acute infection and up to 10% develop a prostatic of recurrent UTI, is generally caused by a bacterial strain sepa- abscess. rate from the original infection and presents more than Presenting symptoms include sudden fever, pelvic or per- 2 weeks after treatment cessation for the previous infection. ineal pain, urinary frequency and dysuria, and increasing Assuming the organism is sensitive, patients r,t ith relapsed obstructive symptoms. Acute bacterial prostatitis frequently infection are treated for a presumed upper UTI for 7 to 10 days presents as a severe systemic infection, with bacteremia occur with the same antibiotic as initially prescribed or, if bacterial ring in approximately 25"/. of patients. Cautious digital rectal resistance is discovered, an alternative agent. Likewise, the examination of the prostate reveals a boggz and tender gland. same first-line antimicrobial agent can be given for reinfec Urinalysis and culture are required to confirm the diagnosis. tions, although an alternative antibiotic should be used if the Although pyuria may occur for reasons other than infection, recurrence occurs within 6 months, particularly if the original its absence strongly indicates no infection. Prostate-specific agent was trimethoprim-sulfamethoxazole, because of the antigen tests should be avoided because results may be ele- increased chance of resistance. Cystoscopy and imaging stud- vated because of inflammation of the gland. ies are indicated only when structural abnormalities or Hospitalized patients and those with severe infection obstruction are potential risk factors. require blood cultures. Gram negative uropathogens account Strategies to prevent infection recurrence include antimi- for about B0% of infections, two thirds of which are E. coli; crobial and nonantimicrobial interventions, such as spermi- Proteus, Enterobacter, Serratia, Klebsiello, and sometimes cide contraceptive avoidance and topical vaginal estrogen Pseudomonos and enterococcal species compose most of the use in postmenopausal women without contraindications. other pathogens. In men 35 years or younger. sexually trans Cranberry products have not been proven effective in con- mitted infections, including Neisserio gonorrhoeoe and trolled trials. Prophylactic daily antimicrobial agents have Chlamydia trachomotis, must be considered. been found to reduce the risk of recurrences by nearly 957,; Fluoroquinolone antibiotics (ciprofloxacin, levofloxa- they are an option in women who have had three or more UTIs cin) may be the preferred oral agents for treating acute in the previous 12 months, or two or more in the previous bacterial prostatitis but should not be used if recent geni- 6 months, and have received no benefit from other prevention tourinary instrumentation was performed because most efforts. Prophylactic therapy may be considered in pregnant E. coli strains are now resistant to fluoroquinolones. 31