140.1 🎓 醫學生版

分類:
- Uncomplicated cystitis: 女性、非孕、healthy
- Complicated: 男性 / 孕婦 / DM / immunocompromised / catheter / urinary obstruction / kidney transplant / 兒童
- Pyelonephritis: upper UTI; fever, flank pain, CVA tenderness
- Prostatitis: acute (febrile, severe) vs chronic
病原:
- Uncomplicated: E. coli (75-90%), S. saprophyticus (young female), Klebsiella, Proteus
- Complicated: + Enterobacter, Serratia, Pseudomonas, Enterococcus, Candida (catheter)
Empirical (2024 IDSA):
- Uncomplicated cystitis female: Nitrofurantoin 100 mg BID × 5 d OR Fosfomycin 3g single OR TMP-SMX 1 DS BID × 3 d (if local resistance < 20%)
- Pyelonephritis (outpatient): Ciprofloxacin 500 mg BID × 7 d OR Levofloxacin OR TMP-SMX × 14 d; + 1-dose ceftriaxone or aminoglycoside if local FQ resistance > 10%
- Pyelonephritis (inpatient / severe): Ceftriaxone 1-2g IV OR Pip-tazo OR Carbapenem if ESBL
不需 routine catheter for asymptomatic bacteriuria UNLESS pregnant or pre-urologic procedure

Dysuria, frequency, urgency, suprapubic pain — no fever / flank pain
無需 urine culture for typical case (empirical OK)
Urinalysis: pyuria (WBC ≥ 5/HPF), bacteriuria, nitrites + (specific to GN like E. coli)

藥物	Dosing	Duration
Nitrofurantoin macrocrystal	100 mg BID	5 days
Fosfomycin	3g PO single	1 dose
TMP-SMX DS	BID	3 days (if local resistance < 20%)
Pivmecillinam	400 mg TID	5-7 d (Europe; not US)

Cephalosporin (cefpodoxime, cefdinir) × 5-7 d
Amoxicillin-clavulanate × 5-7 d
Fluoroquinolone: avoid if possible (collateral damage, C. diff, AAA risk) — reserve for severe / no alternative

Recurrent UTI (≥ 2/6 mo or ≥ 3/year):
- Self-start Tx
- Postcoital prophylaxis if related to intercourse
- Daily low-dose prophylaxis (nitrofurantoin 50-100 mg, TMP-SMX 1/2 DS) × 6 mo
- Cranberry, methenamine, probiotics: limited evidence
- Estrogen vaginal cream (postmenopausal)

Urine culture + Gram + sensitivity (ALWAYS)
Blood cultures × 2 (if febrile / severe)
Lab: CBC, BUN/Cr, electrolytes
Imaging if: complicated (DM, immunocompromised, failed Tx, suspected obstruction / abscess) → CT with contrast (ureteral stone, abscess, emphysematous PN)

嚴重度	Empirical
Outpatient (stable, no DM, oral tolerance)	Ciprofloxacin 500 mg BID × 7 d OR Levofloxacin 750 mg × 5-7 d; OR TMP-SMX × 14 d (+ initial ceftri 1g IV if FQ resistance suspect)
Inpatient mild-moderate	Ceftriaxone 1-2g IV OR Pip-tazo (if MDR risk)
Severe / sepsis / ICU	Pip-tazo or Cefepime + Aminoglycoside; OR Meropenem if ESBL
De-escalate by culture: PO 7-14 d total

Fever + dysuria + perineal pain + tender swollen prostate on DRE (⚠️ avoid vigorous massage — bacteremia)
Pathogen: E. coli (#1), other Enterobacteriaceae, occasionally GC/Chlamydia in young
Tx: Cipro 500 mg BID OR Levofloxacin × 4-6 wks (penetration good); ceftriaxone IV if severe; TMP-SMX × 6 wks alternative

~ 25% catheter users get bacteriuria; 5-10% → CAUTI
Definition: symptomatic + positive urine culture (≥ 10^3 CFU)
Asymptomatic bacteriuria = NO treatment (except pregnant, pre-urologic procedure, < 1 yr post-transplant)
Tx: change/remove catheter + empirical (依 local antibiogram, often pip-tazo or carbapenem); 7-14 d
Prevention: minimize catheter days, sterile insertion, daily eval for removal, don’t routine culture asymptomatic catheter