Case 087: Complicated Urinary Tract Infections

PATIENT PRESENTATION

Chief Complaint

Dysuria, right sided flank pain

History of Present Illness

Mr. Lee is a 40-year-old male who presents with fever, chills, and dysuria with associated right sided flank pain. He was seen at urgent care two days ago for dysuria, started on amoxicillin 500mg PO q8hrs x 5 days, but his symptoms have not improved over the last 48hrs.

Link to EMR

Student Work-Up

TARGETED QUESTIONS

1. What risk factors and characteristics does the patient have consistent with a complicated UTI?

   Hint: See Clinical Presentation and Diagnosis in PPP

2. How does the patient being male affect your decision to diagnose and treat a complicated UTI?

   Hint: See Treatment in PPP

3. The team would like to admit the patient for observation overnight. What intravenous antibiotic would you like to start the patient on today?

   Hint: See Treatment and Table 82-2 in PPP

4. How long should the patient continue complicated UTI antibiotic therapy?

   Hint: See Treatment in PPP

5. How should the patient be monitored for resolution of infection and ADEs?

   Hint: See Treatment in PPP

FOLLOW-UP

The patient is feeling better after receiving the intravenous medication you recommended yesterday. The team would like to give one more dose of the intravenous medication and discharge the patient home on an oral regimen to complete an appropriate course for his infection. What would be an appropriate oral regimen for the patient?

Hint: See Treatment and Table 82-3 in PPP

CASE SUMMARY

Global Perspective

Patients with symptomatic urinary tract infections (UTI), including cystitis and pyelonephritis, should be treated with an appropriate course of antibiotics. It is also important to be cognizant of asymptomatic bacteriuria (ASB), which is frequently identified in hospitalized patients. According to the Infectious Diseases Society of America (IDSA), ASB is defined as isolation of 1 or more bacteria species in the urine (≥ 10⁵ colony forming units [CFU]/mL) in the absence of signs or symptoms consistent with a UTI.¹ Most patients with ASB should not receive antimicrobial therapy. Exceptions to no treating would include treating patients with ASB who are pregnant or who are to undergo an endoscopic urological procedure where there is a risk of mucosal trauma. Otherwise treating ASB patients in the acute care hospital setting does not improve outcomes and has been associated with a longer duration of hospitalization.²

Key References