345.1 🎓 醫孞生版

345.1.0.1 📌 䞀頁重點

345.1.0.1.1 Definitions + Classification

345.1.1 Uncomplicated UTI

  • Premenopausal, non-pregnant women with no structural/functional abnormalities
  • Often acute cystitis
  • Excellent prognosis

345.1.2 Complicated UTI

  • Men (anatomic factors)
  • Pregnancy
  • Children
  • Anatomic / functional abnormalities:
    • Stones
    • Obstruction
    • Reflux
    • Catheters / instrumentation
  • Comorbidities:
    • Diabetes
    • Immunocompromise
    • CKD
  • Higher risk of complications

345.1.3 Acute Cystitis

  • Lower UTI (bladder)
  • Dysuria, frequency, urgency, suprapubic pain
  • ± Mild hematuria
  • No fever, no flank pain

345.1.4 Acute Pyelonephritis

  • Upper UTI (kidney)
  • Fever + flank pain
    • Cystitis symptoms
  • Nausea, vomiting
  • Costovertebral angle tenderness

345.1.5 Asymptomatic Bacteriuria (ASB)

  • Positive culture without symptoms
  • Treat only:
    • Pregnancy
    • Pre-urologic procedure with mucosal trauma
  • Most other cases: do NOT treat (resistance, side effects)

345.1.6 Recurrent UTI

  • ≥ 2 in 6 months OR ≥ 3 in 12 months
  • Common in some women
  • Workup if complicated features

345.1.7 Catheter-Associated UTI (CAUTI)

  • Common HAI
  • Distinguish from asymptomatic catheter bacteriuria
  • Symptoms or signs needed for “UTI”
345.1.7.0.1 Pathogens

345.1.8 Uncomplicated UTI

  • Escherichia coli (75-95%)
  • Staphylococcus saprophyticus (5-10% young women)
  • Klebsiella pneumoniae
  • Proteus mirabilis (urease — struvite stones)
  • Enterococcus faecalis (5-10%)

345.1.9 Complicated UTI

  • E. coli (less dominant)
  • Pseudomonas aeruginosa (instrumentation)
  • Enterococcus
  • Staphylococcus aureus
  • ESBL Enterobacteriaceae
  • Candida (catheter)

345.1.10 Sexually Transmitted Causes (Dysuria)

  • Chlamydia trachomatis
  • Neisseria gonorrhoeae
  • Mycoplasma genitalium
  • Trichomonas

345.1.11 Sterile Pyuria

  • Negative culture but pyuria
  • Causes: STI, TB, interstitial nephritis, kidney stones, urethritis, instrumentation, viral
345.1.11.0.1 Diagnosis

345.1.12 Clinical

  • Acute cystitis: dysuria + frequency + urgency
  • Pyelonephritis: + fever + CVA tenderness
  • Prostatitis: pelvic/perineal pain + voiding symptoms

345.1.13 Urinalysis

  • Leukocyte esterase: pyuria
  • Nitrites: gram-negative bacteria (E. coli most positive; Pseudomonas + Enterococcus often negative)
  • Hematuria
  • Bacteria on microscopy

345.1.14 Urine Culture

  • Gold standard for diagnosis
  • ≥ 10^5 CFU/mL (clean catch)

  • 10^2 CFU/mL with symptoms (some studies)

  • ≥ 10^2 CFU/mL straight catheter

345.1.15 Imaging (Selective)

  • CT if:
    • Suspected obstruction
    • Treatment failure
    • Suspected abscess
    • Complicated UTI
  • Renal US for hydronephrosis
345.1.15.0.1 Treatment

345.1.16 Acute Uncomplicated Cystitis

First-Line: - Nitrofurantoin 100 mg BID × 5 days - TMP-SMX 160/800 BID × 3 days (if local resistance < 20%) - Fosfomycin 3 g single dose

Second-Line (resistance, allergy): - Cephalexin 500 mg BID × 5-7 days - β-lactams (amoxicillin-clavulanate, cefdinir)

Fluoroquinolones (ciprofloxacin, levofloxacin): - Reserve for severe / refractory - Save antibiograms — high resistance + collateral damage - Side effects: tendinopathy, QT, C. diff, peripheral neuropathy

345.1.17 Acute Pyelonephritis

Outpatient (Mild-Moderate): - Fluoroquinolone (ciprofloxacin 500 mg BID or levofloxacin 750 mg daily) × 5-7 days - TMP-SMX × 14 days (if susceptible) - Cephalexin options - Initial single dose IV antibiotic before discharge sometimes

Inpatient (Severe): - IV ceftriaxone 1-2 g daily - IV fluoroquinolone - IV piperacillin-tazobactam (severe, complicated) - Aminoglycoside for severe (caution renal) - Targeted per culture - Switch to oral when clinically improved

Duration: - Uncomplicated pyelonephritis: 7-14 days - Complicated: 14-21 days - Bacteremic: 14 days minimum

345.1.18 Complicated UTI

  • Broader spectrum initial
  • Imaging if poor response
  • Address underlying (obstruction, stone, catheter)
  • 7-14 days typical

345.1.19 CAUTI

  • Remove or change catheter
  • Antibiotics based on culture
  • Avoid empiric coverage of asymptomatic catheter bacteriuria

345.1.20 MDR + ESBL / CRE

ESBL Enterobacteriaceae: - Carbapenem (ertapenem if ESBL only; meropenem for serious) - Avoid cephalosporins - Fosfomycin for uncomplicated cystitis

CRE (Carbapenem-Resistant Enterobacteriaceae): - Ceftazidime-avibactam - Meropenem-vaborbactam - Imipenem-relebactam - Cefiderocol - Colistin (last resort; nephrotoxic)

MDR Pseudomonas: - Ceftolozane-tazobactam - Ceftazidime-avibactam - Cefiderocol

345.1.20.0.1 Recurrent UTI

345.1.21 Causes

  • Behavioral (sexual activity, hygiene)
  • Anatomic (incomplete emptying)
  • Postmenopausal (vaginal atrophy)
  • Diabetes

345.1.22 Prevention

Lifestyle: - Adequate hydration - Post-coital voiding - Avoid bath additives, irritants

Postcoital Prophylaxis: - Single-dose TMP-SMX or nitrofurantoin after sex - For sexually active women

Continuous Prophylaxis (3-6 months): - TMP-SMX 1/2 tab daily - Nitrofurantoin 50-100 mg daily - Cephalexin 125-250 mg daily - Resistance concern

Non-Antibiotic: - Cranberry products — modest evidence; reduce recurrence ~ 25% - D-mannose — emerging - Methenamine hippurate (ALTAR 2022) — alternative - Vaginal estrogen (postmenopausal) — effective

Probiotics — variable evidence

345.1.23 Workup for Recurrent UTI

  • Voiding diary
  • Urinalysis after recovery
  • Urine culture during recurrence
  • Postvoid residual
  • Imaging if complicated features

345.1.24 Vaccines (Emerging)

  • Uromune (MV140) — sublingual; reduces recurrence
  • StroVax — being developed
345.1.24.0.1 Prostatitis

345.1.25 Categories (NIH Classification)

  • I. Acute bacterial prostatitis
  • II. Chronic bacterial prostatitis
  • III. Chronic prostatitis / chronic pelvic pain syndrome (CP/CPPS):
    • IIIA: inflammatory
    • IIIB: non-inflammatory
  • IV. Asymptomatic inflammatory prostatitis

345.1.26 Acute Bacterial Prostatitis

Clinical: - Acute pain (perineum, suprapubic, low back) - Voiding symptoms (dysuria, frequency, urgency) - Fever, chills - Bacteremia possible - Tender, boggy prostate (avoid massage — bacteremia)

Pathogens: - E. coli - Klebsiella - Pseudomonas (catheter) - Other GNR

Treatment: - Fluoroquinolone (ciprofloxacin 500 BID) — penetrates prostate - TMP-SMX alternative - IV initially if severe - Duration: 4-6 weeks (long; prostate penetration limited)

345.1.27 Chronic Bacterial Prostatitis

Clinical: - Recurrent UTIs with same organism - Persistent symptoms - Often subtle

Diagnosis: - Localizing 4-glass test (Meares-Stamey) or 2-glass test - Bacterial growth from prostatic secretions

Treatment: - Fluoroquinolone × 4-6 weeks - TMP-SMX alternative - Limit recurrence

345.1.28 CP/CPPS

Clinical: - Pelvic pain ≥ 3 months - No infection - Voiding symptoms

Treatment: - Multidisciplinary - α-blockers (tamsulosin) - NSAIDs - Trigger point release - Physical therapy - Antidepressants (some) - Pregabalin

345.1.28.1 🩺 床邊速查

  • Acute cystitis: nitrofurantoin 100 BID × 5 d OR TMP-SMX × 3 d OR fosfomycin single dose
  • Pyelonephritis outpatient: ciprofloxacin × 5-7 d
  • Inpatient: ceftriaxone or pip-tazo
  • Recurrent UTI prevention: postcoital prophylaxis, methenamine, vaginal estrogen
  • CAUTI: remove catheter + culture-guided
  • Asymptomatic bacteriuria: treat only in pregnancy and pre-urologic procedure
  • Acute bacterial prostatitis: fluoroquinolone × 4-6 weeks
  • CP/CPPS: multidisciplinary; α-blockers, NSAIDs