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Urinary Tract Infection (UTI) and Cystitis (Bladder Infection) in Females

Overview

Practice Essentials

Urinary tract infections (UTIs) occur far more commonly in women, accounting for at least 8 million visits to various types of healthcare facilities in the United States per year. Cystitis (bladder infection) represents most of these infections (see the image below). 20% of women suffer from at least one UTI in their lifetime. Related terms include pyelonephritis, which refers to upper UTI, and bacteriuria or funguria, which describe findings of bacteria or yeast, respectively, in the urine.

Formulation of a successful diagnostic and treatment plan is based on determining the location of the UTI; underlying physical impairments of the patient, such as diabetes; complicating factors such as nephrolithiasis; prostatic abnormalities; and the presence of resistant organisms.^[1]

Plain radiograph in a 63-year-old patient with poorly controlled type 2 diabetes mellitus shows emphysematous cystitis.

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Terminology of UTIs

The use of valid terminology is essential to making the correct diagnosis and formulating an appropriate treatment plan.

Asymptomatic bacteriuria describes an asymptomatic individual with two consecutive positive urine cultures with the same organism (> 105 CFU ).

Pyelonephritis indicates kidney, upper tract involvement.

Uncomplicated UTIs are infections that develop in healthy men or women with completely normal genitourinary systems.

Complicated UTIs involve hosts that suffer from underlying medical conditions (eg, diabetes mellitus) or various anatomic abnormalities that make them prone to infection.

Signs and symptoms

Symptoms and signs of UTI in adults are as follows:

Dysuria
Urinary urgency and frequency
A sensation of bladder fullness or lower abdominal discomfort
Suprapubic tenderness
Flank pain and costovertebral angle tenderness (may be present in cystitis but suggest upper UTI)
Bloody urine
Fevers, chills, and malaise (may be noted in patients with cystitis, but more frequently associated with upper UTI)

See Clinical Presentation for more detail.

Diagnosis

Diagnostic studies for UTI consist of dipstick, urinalysis, and culture. No imaging studies are indicated in the routine evaluation of cystitis.

Current emphasis in the diagnosis of UTI rests with the detection of pyuria, as follows:

A positive leukocyte esterase dipstick test suffices in most instances
In females with clinical findings suggestive of UTI, urine microscopy may be indicated even if the leukocyte esterase dipstick test is negative
Pyuria is most accurately measured by counting leukocytes in unspun fresh urine using a hemocytometer chamber; more than 10 white blood cells (WBCs)/mL is abnormal

Other findings are as follows:

Microscopic hematuria is found in about half of cystitis cases
Low-grade proteinuria is common
A positive nitrite test is highly specific for UTI, but it occurs in only 25% of patients with UTI

Urine culture remains the criterion standard for the diagnosis of UTI. Consider obtaining urine cultures in patients with probable cystitis if any of the following is present:

Immunosuppression
Recent urinary tract instrumentation
Recent exposure to antibiotics
Recurrent infection
Advanced age

Definitions of UTI in women, based on culture results in clean-catch urine specimens, are as follows:

Cystitis: More than 1000 colony-forming units (CFU)/mL
Pyelonephritis: More than 10,000 CFU/mL

Any amount of uropathogen grown in culture from a suprapubic aspirate should be considered evidence of a UTI.

See Workup for more detail.

Management

Oral therapy with an empirically chosen antibiotic that is effective against gram-negative aerobic coliform bacteria (eg, Escherichia coli) is the principal treatment intervention in patients with cystitis. The first-choice agents for treatment of uncomplicated acute cystitis in women include the following:

Nitrofurantoin monohydrate/macrocrystals
Trimethoprim-sulfamethoxazole (TMP-SMX)
Fosfomycin

Considerations in antibiotic selection are as follows:

Empiric antibiotic selection is determined in part by local resistance patterns
Beta-lactam antibiotics (eg, amoxicillin-clavulanate, cefdinir, cefaclor, cefpodoxime-proxetil) may be used when other recommended agents cannot be used^{[2, 3]}
Fosfomycin and nitrofurantoin monohydrate/macrocrystals should be avoided in patients with possible early pyelonephritis^[2]
Clinicians may wish to limit use of TMP-SMX, to reduce the emergence of resistant organisms
Fluoroquinolones typically are reserved for complicated cystitis

Duration of antibiotic treatment for acute, uncomplicated cystitis in women who are not pregnant is as follows:

TMP-SMX is given for 3 days
Fosfomycin is given in a single dose
Nitrofurantoin monohydrate/macrocrystals is given for 5-7 days
Beta-lactam agents are given for 3–7-days
For cystitis in older women or infection caused by Staphylococcus saprophyticus, 7 days of therapy is suggested

The vast majority of women with UTI present on an ambulatory basis and can be treated as outpatients. Hospital admission may be indicated for some patients with complicated UTI. Complicating factors include the following:

Structural abnormalities (eg, calculi, tract anomalies, indwelling catheter, obstruction)
Metabolic disease (eg, diabetes, renal insufficiency)
Impaired host defenses (eg, HIV infection, current chemotherapy, underlying active cancer)

See Treatment and Medication for more detail.

Background

UTI is defined as significant bacteriuria in the setting of symptoms of cystitis or pyelonephritis. These infections account for a significant number of emergency department (ED) visits,^[4]and 20% of women develop at least one UTI. (See Epidemiology.)

Escherichia coli causes the majority of uncomplicated cystitis cases. Among the pathogens responsible for the remainder are Staphylococcus saprophyticus, Proteus mirabilis, Klebsiella pneumoniae, or Enterococcus faecalis. (See Etiology.)

A presumptive diagnosis of uncomplicated cystitis can be made on the basis of findings of the history and physical examination, along with urinalysis.^{[5, 6]}Proper specimen collection is necessary. In addition, clinicians need to appreciate the epidemiologic and host factors that may identify patients with complicated cystitis or clinically inapparent upper UTI, in whom more comprehensive assessment is indicated. (See Workup.)

Successful emergent management includes selection of appropriate antimicrobial therapy with recommendations for follow-up care. Oral therapy with an antibiotic effective against gram-negative aerobic coliform bacteria is the principal therapeutic intervention in patients with cystitis. (See Treatment, as well as Medication.)

The following terms are defined for uniformity in this article:

Asymptomatic bacteriuria (ASB) refers to 2 consecutive urine cultures growing more than 100,000 colony-forming units (CFU)/mL of a bacterial species in a patient lacking symptoms of a UTI
Uropathogens are bacteria with specific virulence factors that facilitate their invasion of the urinary tract
Complicated UTIs are defined as UTIs that are associated with metabolic disorders, that are secondary to anatomic or functional abnormalities that impair urinary tract drainage, or that involve unusual pathogens (eg, yeast), which increase the risk for therapeutic failure

Pathophysiology

The urinary tract normally is sterile. Uncomplicated UTI involves the urinary bladder in a host without underlying renal, metabolic, or neurologic diseases. Cystitis represents bladder mucosal invasion, most often by enteric coliform bacteria (eg, Escherichia coli) that inhabit the periurethral vaginal introitus and ascend into the bladder via the urethra.

In recurrent E coli UTIs, peak colonization rates of the periurethral area 2-3 days prior to the development of the symptoms of acute cystitis range from 46-90%. During this same period, asymptomatic bacteriuria rates increase from 7-70%.^[7]

Because sexual intercourse may promote this migration, cystitis is common in otherwise healthy young women. Generally, urine is a good culture medium. Factors unfavorable to bacterial growth include a low pH (5.5 or less), a high concentration of urea, and the presence of organic acids derived from a diet that includes fruits and protein. Organic acids enhance acidification of the urine.

Frequent and complete voiding has been associated with a reduction in the incidence of UTI. Normally, a thin film of urine remains in the bladder after emptying, and any bacteria present are removed by the mucosal cell production of organic acids.

If the defense mechanisms of the lower urinary tract fail, upper tract or kidney involvement occurs and is termed pyelonephritis. Host defenses at this level include local leukocyte phagocytosis and renal production of antibodies that kill bacteria in the presence of complement. For more information on this topic, see the Medscape Reference articles Acute Pyelonephritis and Pathophysiology of Complicated Urinary Tract Infections.

In general, there are 3 main mechanisms responsible for UTIs:

Colonization with ascending spread
Hematogenous spread
Periurogenital spread

Bacterial virulence

Uropathogenic bacteria, derived from a subset of fecal flora, have traits that enable adherence, growth, and resistance of host defenses. These traits facilitate colonization and infection of the urinary tract.

Adhesins are bacterial surface structures that enable attachment to host membranes. In E coli infection, these include both pili (ie, fimbriae) and outer-membrane proteins (eg, Dr hemagglutinin that binds to Dr blood group antigen). P fimbriae, which attach to globoseries-type glycolipids found in the colon and urinary epithelium, are associated with pyelonephritis and cystitis and are found in many E coli strains that cause urosepsis.

Type 1 fimbriae bind to mannose-containing structures found in many different cell types, including Tamm-Horsfall protein (the major protein found in human urine). Whether this facilitates or inhibits uroepithelial colonization is the subject of some debate.

Other factors that may be important for E coli virulence in the urinary tract include capsular polysaccharides, hemolysins, cytotoxic necrotizing factor (CNF) protein, and aerobactins. Several Kauffman serogroups of E coli that contain these virulence factors may be more likely to cause UTIs, including O1, O2, O4, O6, O16, and O18.

Another example of bacterial virulence is the swarming capability of Proteus mirabilis. Swarming involves the expression of specific genes when these bacteria are exposed to surfaces such as catheters. This results in the coordinated movement of large numbers of bacteria, enabling P mirabilis to move across solid surfaces. This likely explains the association of P mirabilis UTIs with instrumentation of the urinary tract.

Host resistance

Most uropathogens gain access to the urinary tract via an ascending route. The shorter length of the female urethra allows uropathogens easier access to the bladder. The continuous unidirectional flow of urine helps to minimize UTIs, and anything that interferes with this increases the host's susceptibility to UTI. Examples of interference include volume depletion, sexual intercourse, urinary tract obstruction, instrumentation, use of catheters not drained to gravity, and vesicoureteral reflux.

Secretory defenses help promote bacterial clearance and prevent adherence. Secretory immunoglobulin A (IgA) reduces attachment and invasion of bacteria in the urinary tract. Women who are nonsecretors of the ABH blood antigens appear to be at higher risk for recurrent UTIs; this may occur because of a lack of specific glycosyltransferases that modify epithelial surface glycolipids, allowing E coli to bind to them better.

In premenopausal women, lactobacilli are the predominant vaginal flora and serve to suppress vaginal colonization by the uropathogens. Most antibiotics, except sulfamethoxazole and the quinolones, can eradicate these protective bacteria.

Urine itself has several antibacterial features that suppress UTIs. Specifically, the pH, urea concentration, osmolarity, and various organic acids prevent most bacteria from surviving in the urinary tract.

Etiology

E coli causes 70-95% of both upper and lower UTIs. Various organisms are responsible for the remainder of infections, including S saprophyticus, Proteus species, Klebsiella species, Enterococcus faecalis, other Enterobacteriaceae, and yeast. Some species are more common in certain subgroups, such as Staphylococcus saprophyticus in young women. However, S saprophyticus can produce acute cystitis in older women and in young men and should not be automatically regarded as a contaminant in the urine cultures of these individuals.^[8]

Most complicated UTIs are nosocomial in origin. Increasingly, UTIs in patients in healthcare institutions and in those with frequent antibiotic exposure are caused by multidrug-resistant gram-negative pathogens, such as extended-spectrum beta-lactamase (ESBL) and carbapenemase producers. However, the prevalence of multidrug-resistant pathogens varies by locale.^[9]

The most important risk factor for bacteriuria is the presence of a catheter.^[10]Eighty percent of nosocomial UTIs are related to urethral catheterization, whereas 5-10% are related to genitourinary manipulation. Catheters inoculate organisms into the bladder and promote colonization by providing a surface for bacterial adhesion and causing mucosal irritation. For more information on this topic, see the Medscape Reference article Catheter-Related Urinary Tract Infection.

Sexual intercourse contributes to increased risk, as does use of a diaphragm and/or spermicide. Routine pelvic examinations also are associated with an increased risk for UTI for 7 weeks post procedure.^[11]Women who are elderly, are pregnant, or have preexisting urinary tract structural abnormalities or obstruction carry a higher risk for UTI.

UTIs are the most common type of infection after renal transplantation. Susceptibility is especially high in the first 2 months following transplantation. Triggering factors include vesicoureteral reflux and immunosuppression. Corynebacterium urealyticum (ie, CDC group D2) has been reported to cause encrusted pyelitis and cystitis in these patients.

Calculi related to UTIs most commonly occur in women who experience recurrent UTIs with Proteus, Pseudomonas, and Providencia species. Perinephric abscesses most commonly are associated with E coli, Proteus species, and S aureus but also may be secondary to Enterobacter, Citrobacter, Serratia, Pseudomonas, and Klebsiella species. More unusual causes include enterococci, Candida species, anaerobes, Actinomyces species, and Mycobacterium tuberculosis. Twenty-five percent of infections are polymicrobial.

Candiduria is defined as more than 1000 CFU/mL of yeast from 2 cultures. Candida albicans, which is germ tube positive, is the usual culprit. Germ tube–negative Candida species (tropicalis, parapsilosis, glabrata, lusitaniae, krusei) are less common.

Risk factors for candiduria include diabetes mellitus, indwelling urinary catheters, and antibiotic use. Candiduria may clear spontaneously or may result in (or from) deep fungal infections.

United States statistics

UTIs in women are very common; approximately 25-40% of women in the United States aged 20-40 years have had a UTI. UTIs account for over 6 million patient visits to physicians per year in the United States; approximately 20% of those visits are to EDs.

Cystitis occurs in 0.3%-1.3% of pregnancies but does not appear to be related to asymptomatic bacteriuria. Acute pyelonephritis occurs in 1-2% of pregnancies. UTIs occur in 3-50% of renal transplant patients and frequently are silent.

In 2007, approximately 3.9% of office visits were related to symptoms involving the genitourinary tract.^[12]Estimates based on office and ED visits suggest per annum about 7 million episodes of acute cystitis. Some studies estimate that UTIs (cystitis plus pyelonephritis) cost at least $1 billion per year.

International statistics

UTIs have been well studied in Sweden and other parts of Europe.^[13]These studies have shown that 1 in 5 adult women experience a UTI at some point, confirming that it is an exceedingly common worldwide problem.

The epidemiology of UTI in the tropics is less well documented. UTIs appear to be common and associated with structural abnormalities. Chronic infection from Schistosoma haematobium disrupts bladder mucosal integrity and causes urinary tract obstruction and stasis. Salmonella bacteriuria, with or without bacteremia, is very common in patients with schistosomiasis. Treatment requires both antischistosomal and anti-Salmonella agents.

Age- and sex-related demographics

Uncomplicated UTIs are much more common in women than men when matched for age. A study of Norwegian men aged 21-50 years showed an approximate incidence of 0.0006-0.0008 infections per person-year, compared with approximately 0.5-0.7 per person-year in similarly aged women in the United States.

The largest group of patients with UTI is adult women. The incidence of UTI in women tends to rise with increasing age. Several peaks above baseline correspond with specific events, including an increase in women aged 18-30 years (associated with coitus—so-called honeymoon cystitis—and pregnancy).

Rates of infection are high in postmenopausal women because of bladder or uterine prolapse causing incomplete bladder emptying; loss of estrogen with attendant changes in vaginal flora (notably, loss of lactobacilli), which allows periurethral colonization with gram-negative aerobes, such as E coli; and higher likelihood of concomitant medical illness, such as diabetes.

Of neonates, boys are slightly more likely than girls to present with UTI as part of a gram-negative sepsis syndrome. The incidence in preschool-aged children is approximately 2% and is 10 times more common in girls. UTI occurs in 5% of school-aged girls, but it is rare in school-aged boys.

Prognosis

Even with effective antibiotic treatment, the average duration of severe symptoms in women with cystitis is somewhat longer than 3 days. Features that have been associated with a more prolonged course than average include a history of somatization, previous cystitis, urinary frequency, and more severe symptoms at baseline.^[14]

Although simple lower UTI (cystitis) may resolve spontaneously, effective treatment lessens the duration of symptoms and reduces the incidence of progression to upper UTI. Even with effective treatment, however, about 25% of women with cystitis will experience a recurrence.

Younger patients have the lowest rates of morbidity and mortality. Factors associated with an unfavorable prognosis include the following:

Old age
General debility
Renal calculi or obstruction
Recent hospitalization
Urinary tract instrumentation or antibiotic therapy
Diabetes mellitus
Chronic nephropathy
Sickle cell anemia
Underlying cancer
Intercurrent chemotherapy

The mortality associated with acute uncomplicated cystitis in women aged 20-60 years appears to be negligible. A longitudinal cohort study of Swedish women showed a higher mortality in women with a history of UTI than in age-matched women without such a history (37% vs 28% in 10 y),^[15]but these cohorts were not matched for other mortality-related factors, making it difficult to attribute the increased mortality to UTIs.

In contrast, the morbidity in terms of quality of life and economic measures is tremendous. Each episode of UTI in a young woman results in an average of 6.1 days of symptoms, 1.2 days of decreased class/work attendance, and 0.4 days in bed.

Nosocomial infections develop in about 5% of patients admitted to hospitals, and UTIs account for 40% of these infections. From 2-4% of these patients become bacteremic, with a mortality of 12.5%.

Patient Education

Proper adherence to the outpatient medical regimen should be stressed. Behavior modification, such as good oral fluid intake to enhance diuresis and frequent voiding (including postintercourse voiding) may be helpful in reducing recurrent infection.

For patient education information, see the Infections Center, as well as Urinary Tract Infection (UTI), Blood in the Urine, Birth Control Overview, Birth Control Spermicides, and Birth Control FAQs.

Clinical Presentation

Liu P, Hamilton KW, O'Donnnell JA. Urinary Tract Infection. Cunha CB. Schlosberg Clinical Infectious Disease. Third. Oxford University Press; 2022. 423-429.
[Guideline] Gupta K, Hooton TM, Naber KG, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis. 2011 Mar. 52(5):e103-20. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Wagenlehner FM, Schmiemann G, Hoyme U, Fünfstück R, Hummers-Pradier E, Kaase M, et al. [National S3 guideline on uncomplicated urinary tract infection: recommendations for treatment and management of uncomplicated community-acquired bacterial urinary tract infections in adult patients]. Urologe A. 2011 Feb. 50(2):153-69. [QxMD MEDLINE Link]. [Full Text].
Abrahamian FM, Moran GJ, Talan DA. Urinary tract infections in the emergency department. Infect Dis Clin North Am. 2008 Mar. 22(1):73-87, vi. [QxMD MEDLINE Link].
Little P, Turner S, Rumsby K, Warner G, Moore M, Lowes JA, et al. Dipsticks and diagnostic algorithms in urinary tract infection: development and validation, randomised trial, economic analysis, observational cohort and qualitative study. Health Technol Assess. 2009 Mar. 13(19):iii-iv, ix-xi, 1-73. [QxMD MEDLINE Link].
Lane DR, Takhar SS. Diagnosis and management of urinary tract infection and pyelonephritis. Emerg Med Clin North Am. 2011 Aug. 29(3):539-52. [QxMD MEDLINE Link].
Czaja CA, Stamm WE, Stapleton AE, et al. Prospective cohort study of microbial and inflammatory events immediately preceding Escherichia coli recurrent urinary tract infection in women. J Infect Dis. 2009 Aug 15. 200(4):528-36. [QxMD MEDLINE Link].
Adeghate J, Juhász E, Pongrácz J, Rimanóczy É, Kristóf K. Does Staphylococcus Saprophyticus Cause Acute Cystitis only in Young Females, or is there more to the Story? A One-Year Comprehensive Study Done in Budapest, Hungary. Acta Microbiol Immunol Hung. 2016 Mar. 63 (1):57-67. [QxMD MEDLINE Link].
Kanj SS, Kanafani ZA. Current concepts in antimicrobial therapy against resistant gram-negative organisms: extended-spectrum beta-lactamase-producing Enterobacteriaceae, carbapenem-resistant Enterobacteriaceae, and multidrug-resistant Pseudomonas aeruginosa. Mayo Clin Proc. 2011 Mar. 86(3):250-9. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Hooton TM, Bradley SF, Cardenas DD, et al. Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. Clin Infect Dis. 2010 Mar 1. 50(5):625-63. [QxMD MEDLINE Link]. [Full Text].
Tiemstra JD, Chico PD, Pela E. Genitourinary infections after a routine pelvic exam. J Am Board Fam Med. 2011 May-Jun. 24(3):296-303. [QxMD MEDLINE Link].
Hsiao CJ, Cherry DK, Beatty PC, Rechtsteiner EA. National Ambulatory Medical Care Survey: 2007 summary. Natl Health Stat Report. 2010 Nov 3. 1-32. [QxMD MEDLINE Link].
Naber KG, Schito G, Botto H, Palou J, Mazzei T. Surveillance study in Europe and Brazil on clinical aspects and Antimicrobial Resistance Epidemiology in Females with Cystitis (ARESC): implications for empiric therapy. Eur Urol. 2008 Nov. 54(5):1164-75. [QxMD MEDLINE Link].
Little P, Merriman R, Turner S, Rumsby K, Warner G, Lowes JA, et al. Presentation, pattern, and natural course of severe symptoms, and role of antibiotics and antibiotic resistance among patients presenting with suspected uncomplicated urinary tract infection in primary care: observational study. BMJ. 2010 Feb 5. 340:b5633. [QxMD MEDLINE Link]. [Full Text].
Molander U, Arvidsson L, Milsom I, Sandberg T. A longitudinal cohort study of elderly women with urinary tract infections. Maturitas. 2000 Feb 15. 34(2):127-31. [QxMD MEDLINE Link].
Johnson L, Sabel A, Burman WJ, Everhart RM, Rome M, MacKenzie TD, et al. Emergence of fluoroquinolone resistance in outpatient urinary Escherichia coli isolates. Am J Med. 2008 Oct. 121(10):876-84. [QxMD MEDLINE Link].
[Guideline] American College of Obstetricians and Gynecologists (ACOG). 2008. Treatment of urinary tract infections in nonpregnant women. Available at http://guideline.gov/content.aspx?id=12628. Accessed: September 22, 2010.
Falcone M, Suardi LR, Tiseo G, et al. Superinfections caused by carbapenem-resistant Enterobacterales in hospitalized patients with COVID-19: a multicentre observational study from Italy (CREVID Study). JAC Antimicrob Resist. 2022 Jun. 4 (3):dlac064. [QxMD MEDLINE Link].
Corcione S, Montrucchio G, Shbaklo N, et al. First Cases of Candida auris in a Referral Intensive Care Unit in Piedmont Region, Italy. Microorganisms. 2022 Jul 27. 10 (8):[QxMD MEDLINE Link].
Taylor RA, Moore CL, Cheung KH, Brandt C. Predicting urinary tract infections in the emergency department with machine learning. PLoS One. 2018. 13 (3):e0194085. [QxMD MEDLINE Link].
Barclay L. Urinary Tract Infection: 3 Questions Aid Diagnosis in Women. Medscape Medical News. Available at http://www.medscape.com/viewarticle/810667. Accessed: September 16, 2013.
Knottnerus BJ, Geerlings SE, Moll van Charante EP, Ter Riet G. Toward a simple diagnostic index for acute uncomplicated urinary tract infections. Ann Fam Med. 2013 Sep-Oct. 11(5):442-51. [QxMD MEDLINE Link]. [Full Text].
Schaeffer AJ, Schaeffer EM. Infections of the Urinary Tract. In: McDougal WS, Wein AJ, Kavoussi LR, et al, eds. Campbell-Walsh Urology. 10th Ed. Philadelphia, PA: Elsevier Saunders; 2012. 46-55.
Lifshitz E, Kramer L. Outpatient urine culture: does collection technique matter?. Arch Intern Med. 2000 Sep 11. 160(16):2537-40. [QxMD MEDLINE Link].
Propp DA, Weber D, Ciesla ML. Reliability of a urine dipstick in emergency department patients. Ann Emerg Med. 1989 May. 18(5):560-3. [QxMD MEDLINE Link].
Mehnert-Kay SA. Diagnosis and Management of Uncomplicated Urinary Tract Infections. American Family Physician. August 1, 2005. 27/No.3:1-9. [Full Text].
[Guideline] Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA. Guideline for prevention of catheter-associated urinary tract infections 2009. Infect Control Hosp Epidemiol. 2010 Apr. 31(4):319-26. [QxMD MEDLINE Link]. [Full Text].
Kauffman CA, Fisher JF, Sobel JD, Newman CA. Candida urinary tract infections--diagnosis. Clin Infect Dis. 2011 May. 52 Suppl 6:S452-6. [QxMD MEDLINE Link].
Falagas ME, Kotsantis IK, Vouloumanou EK, Rafailidis PI. Antibiotics versus placebo in the treatment of women with uncomplicated cystitis: a meta-analysis of randomized controlled trials. J Infect. 2009 Feb. 58(2):91-102. [QxMD MEDLINE Link].
Foxman B. The epidemiology of urinary tract infection. Nat Rev Urol. 2010 Dec. 7(12):653-60. [QxMD MEDLINE Link].
Little P, Moore MV, Turner S, Rumsby K, Warner G, Lowes JA, et al. Effectiveness of five different approaches in management of urinary tract infection: randomised controlled trial. BMJ. 2010 Feb 5. 340:c199. [QxMD MEDLINE Link]. [Full Text].
Lavigne JP, Bruyère F, Bernard L, Combescure C, Ronco E, Lanotte P, et al. Resistance and virulence potential of uropathogenic Escherichia coli strains isolated from patients hospitalized in urology departments: a French prospective multicentre study. J Med Microbiol. 2016 Jun. 65 (6):530-7. [QxMD MEDLINE Link].
Christiaens TC, De Meyere M, Verschraegen G, Peersman W, Heytens S, De Maeseneer JM. Randomised controlled trial of nitrofurantoin versus placebo in the treatment of uncomplicated urinary tract infection in adult women. Br J Gen Pract. 2002 Sep. 52(482):729-34. [QxMD MEDLINE Link]. [Full Text].
Bleidorn J, Gágyor I, Kochen MM, Wegscheider K, Hummers-Pradier E. Symptomatic treatment (ibuprofen) or antibiotics (ciprofloxacin) for uncomplicated urinary tract infection?--results of a randomized controlled pilot trial. BMC Med. 2010 May 26. 8:30. [QxMD MEDLINE Link]. [Full Text].
Grigoryan L, Zoorob R, Wang H, Trautner BW. Low Concordance With Guidelines for Treatment of Acute Cystitis in Primary Care. Open Forum Infect Dis. 2015 Dec. 2 (4):ofv159. [QxMD MEDLINE Link].
Sigler M, Leal JE, Bliven K, Cogdill B, Thompson A. Assessment of appropriate antibiotic prescribing for urinary tract infections in an internal medicine clinic. South Med J. 2015 May. 108 (5):300-4. [QxMD MEDLINE Link].
Olson RP, Harrell LJ, Kaye KS. Antibiotic resistance in urinary isolates of Escherichia coli from college women with urinary tract infections. Antimicrob Agents Chemother. 2009 Mar. 53(3):1285-6. [QxMD MEDLINE Link]. [Full Text].
McKinnell JA, Stollenwerk NS, Jung CW, Miller LG. Nitrofurantoin compares favorably to recommended agents as empirical treatment of uncomplicated urinary tract infections in a decision and cost analysis. Mayo Clin Proc. 2011 Jun. 86(6):480-8. [QxMD MEDLINE Link]. [Full Text].
Falagas ME, Vouloumanou EK, Togias AG, Karadima M, Kapaskelis AM, Rafailidis PI, et al. Fosfomycin versus other antibiotics for the treatment of cystitis: a meta-analysis of randomized controlled trials. J Antimicrob Chemother. 2010 Sep. 65(9):1862-77. [QxMD MEDLINE Link]. [Full Text].
Xin H, Rosario-Colon JA, Eberle K. Novel Intravenous Immunoglobulin Therapy for the Prevention and Treatment of Candida auris and Candida albicans Disseminated Candidiasis. mSphere. 2023 Jan 23. e0058422. [QxMD MEDLINE Link].
[Guideline] Nicolle LE, Bradley S, Colgan R, Rice JC, Schaeffer A, Hooton TM. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis. 2005 Mar 1. 40(5):643-54. [QxMD MEDLINE Link]. [Full Text].
Dalal S, Nicolle L, Marrs CF, Zhang L, Harding G, Foxman B. Long-term Escherichia coli asymptomatic bacteriuria among women with diabetes mellitus. Clin Infect Dis. 2009 Aug 15. 49(4):491-7. [QxMD MEDLINE Link]. [Full Text].
Beerepoot MA, ter Riet G, Nys S, et al. Cranberries vs antibiotics to prevent urinary tract infections: a randomized double-blind noninferiority trial in premenopausal women. Arch Intern Med. 2011 Jul 25. 171(14):1270-8. [QxMD MEDLINE Link].
Jepson RG, Craig JC. Cranberries for preventing urinary tract infections. Cochrane Database Syst Rev. 2008 Jan 23. CD001321. [QxMD MEDLINE Link].
Tempera G, Corsello S, Genovese C, Caruso FE, Nicolosi D. Inhibitory activity of cranberry extract on the bacterial adhesiveness in the urine of women: an ex-vivo study. Int J Immunopathol Pharmacol. 2010 Apr-Jun. 23(2):611-8. [QxMD MEDLINE Link].
Frellick M. Drinking More Water Reduces Repeat Urinary Tract Infections. Medscape Medical News. Available at http://www.medscape.com/viewarticle/886775. October 9, 2017; Accessed: October 10, 2017.
De Vita D, Giordano S. Effectiveness of intravesical hyaluronic acid/chondroitin sulfate in recurrent bacterial cystitis: a randomized study. Int Urogynecol J. 2012 Dec. 23(12):1707-13. [QxMD MEDLINE Link].
[Guideline] Anger J, Lee U, Ackerman AL, Chou R, Chughtai B, Clemens JQ, et al. Recurrent Uncomplicated Urinary Tract Infections in Women: AUA/CUA/SUFU Guideline. J Urol. 2019 May 1. 101097JU0000000000000296. [QxMD MEDLINE Link]. [Full Text].
van der Starre WE, van Nieuwkoop C, Paltansing S, et al. Risk factors for fluoroquinolone-resistant Escherichia coli in adults with community-onset febrile urinary tract infection. J Antimicrob Chemother. 2011 Mar. 66(3):650-6. [QxMD MEDLINE Link].
Cloutier DJ, Miller LG, Komirenko AS, Cebrik DS, Krause KM, Keepers TR, et al. Plazomicin Versus Meropenem for the Treatment of Complicated Urinary Tract Infection and Acute Pyelonephritis: Results of the EPIC Study. Presented at the 27th European Congress of Clinical Microbiology and Infectious Diseases (ECCMID), Vienna, Austria, April 22-25, 2017.
Cunha BA. Prophylaxis for recurrent urinary tract infections: nitrofurantoin, not trimethoprim-sulfamethoxazole or cranberry juice. Arch Intern Med. 2012 Jan 9. 172(1):82; author reply 82-3. [QxMD MEDLINE Link].
Cunha BA, Schoch PE, Hage JR. Nitrofurantoin: preferred empiric therapy for community-acquired lower urinary tract infections. Mayo Clin Proc. 2011 Dec. 86(12):1243-4; author reply 1244. [QxMD MEDLINE Link]. [Full Text].
Fischer HD, Juurlink DN, Mamdani MM, Kopp A, Laupacis A. Hemorrhage during warfarin therapy associated with cotrimoxazole and other urinary tract anti-infective agents: a population-based study. Arch Intern Med. 2010 Apr 12. 170(7):617-21. [QxMD MEDLINE Link].
Hand L. Urinary Infections: Report Offers Long-Needed Clarity. Medscape [serial online]. Available at http://www.medscape.com/viewarticle/814305. Accessed: November 18, 2013.
Hooton TM, Roberts PL, Cox ME, Stapleton AE. Voided midstream urine culture and acute cystitis in premenopausal women. N Engl J Med. 2013 Nov 14. 369(20):1883-91. [QxMD MEDLINE Link].
Leydon GM, Turner S, Smith H, Little P. Women's views about management and cause of urinary tract infection: qualitative interview study. BMJ. 2010 Feb 5. 340:c279. [QxMD MEDLINE Link]. [Full Text].
Pinson AG, Philbrick JT, Lindbeck GH, Schorling JB. ED management of acute pyelonephritis in women: a cohort study. Am J Emerg Med. 1994 May. 12(3):271-8. [QxMD MEDLINE Link].
Turner D, Little P, Raftery J, Turner S, Smith H, Rumsby K, et al. Cost effectiveness of management strategies for urinary tract infections: results from randomised controlled trial. BMJ. 2010 Feb 5. 340:c346. [QxMD MEDLINE Link]. [Full Text].

Media Gallery

Nonobstructing distal left ureteral calculus 2 X 1 X 2 cm.
Multiple abscesses, upper pole of left kidney.
Bilateral hydronephrosis.
Plain radiograph in a 63-year-old patient with poorly controlled type 2 diabetes mellitus shows emphysematous cystitis.
Lactobacilli and a squamous epithelial cell are evident on this vaginal smear. The presence of squamous cells and lactobacilli on urinalysis suggests contamination or colonization. Source: Centers for Disease Control and Prevention, Dr. Mike Miller

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Author

John L Brusch, MD, FACP Corresponding Faculty Member, Harvard Medical School

John L Brusch, MD, FACP is a member of the following medical societies: American College of Physicians, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Coauthor(s)

Mary F Bavaro, MD Fellowship Director, Division of Infectious Disease, Navy Medical Center, San Diego

Mary F Bavaro, MD is a member of the following medical societies: American College of Physicians, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Jeffrey M Tessier, MD Assistant Professor, Division of Infectious Diseases, Department of Internal Medicine, Virginia Commonwealth University School of Medicine

Jeffrey M Tessier, MD is a member of the following medical societies: American College of Physicians-American Society of Internal Medicine

Disclosure: Nothing to disclose.

Chief Editor

Michael Stuart Bronze, MD David Ross Boyd Professor and Chairman, Department of Medicine, Stewart G Wolf Endowed Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center; Master of the American College of Physicians; Fellow, Infectious Diseases Society of America; Fellow of the Royal College of Physicians, London

Michael Stuart Bronze, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Medical Association, Association of Professors of Medicine, Infectious Diseases Society of America, Oklahoma State Medical Association, Southern Society for Clinical Investigation

Disclosure: Nothing to disclose.

Additional Contributors

Burke A Cunha, MD Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital

Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Acknowledgements

Michael S Beeson, MD, MBA, FACEP Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine and Pharmacy; Attending Faculty, Akron General Medical Center

Michael S Beeson, MD, MBA, FACEP is a member of the following medical societies: American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, National Association of EMS Physicians, and Society for Academic Emergency Medicine