Urinary Tract Infections in Women: The Right Clinical Information, Right Where It's Needed

Urinary tract
infections in women
The right clinical information, right where it's needed
Last updated: Sep 04, 2019

Table of Contents
Summary 3
Basics 4
Definition 4
Epidemiology 4
Aetiology 4
Pathophysiology 4
Classification 5
Prevention 6
Primary prevention 6
Screening 6
Secondary prevention 6
Diagnosis 7
Case history 7
Step-by-step diagnostic approach 7
Risk factors 9
History & examination factors 10
Diagnostic tests 11
Differential diagnosis 12
Treatment 15
Step-by-step treatment approach 15
Treatment details overview 17
Treatment options 20
Emerging 32
Follow up 33
Recommendations 33
Complications 33
Prognosis 34
Guidelines 35
Diagnostic guidelines 35
Treatment guidelines 35
References 37
Disclaimer 44
Summary
◊ Can be clinically categorised into uncomplicated/complicated, acute, or recurrent.
◊ Escherichia coli is the most common organism in uncomplicated infections.
◊ Costovertebral angle tenderness together with fever suggests pyelonephritis.
◊ Diagnosed using urine dipstick, microscopic urinalysis (bacteria, white blood cell, red blood cell), and
urine culture.
◊ Antibiotic selection should be guided by local bacterial susceptibilities and guidelines, or based on
known urine culture and sensitivity.
Urinary tract infections in women Basics
Definition
A urinary tract infection (UTI) is an infection of the kidneys, bladder, or urethra. Infectious cystitis is the most
common type of UTI, which is caused by a bacterial infection of the bladder. Pyelonephritis is an infection of
BASICS
the kidney that often occurs via bacterial ascent, and urethritis is an infection causing an inflammation of the
urethra.
Epidemiology
Ten percent of women aged older than 18 years report at least one suspected UTI every 12 months.[7]
Approximately 20% to 40% of women with an initial UTI develop recurrent UTI.[8] UTIs are among the
most common conditions encountered in primary care, hospitals, and extended care facilities, and in the
US are responsible for 7 million surgery visits and 1 million hospital admissions each year.[9] Total direct
costs of UTI treatment (without cultures) have been estimated at US $25.5 billion annually.[10] Despite an
exceptionally high prevalence of bacteriuria in the population, these infections rarely cause significant renal
damage.
Aetiology
Escherichia coli is the cause in 70% to 95% of uncomplicated cases, and Staphylococcus saprophyticus
is the cause in 5% to 20% of cases.[11] Other causative pathogens in uncomplicated UTIs include
Enterobacteriaceae such as Proteus mirabilis and Klebsiella species, enterococci, group B streptococci,
Pseudomonas aeruginosa , and Citrobacter genus.
A broad range of bacteria can cause complicated UTIs, and many are resistant to multiple antimicrobial
agents. Citrobacter and Enterobacter genera, P aeruginosa , enterococci, and Staphylococcus aureus
account for a relatively high proportion of cases compared with uncomplicated UTI.[12]
Worldwide, infections caused by gram-negative strains (e.g., E coli , Enterobacteriaceae, Ps aeruginosa

, or Acinetobacter genus infection) have increasing rates of resistance to the main antibiotic classes.[13]
Localised knowledge of the common causative pathogens of UTIs, including local susceptibility patterns, is
essential for the judicious use of antibiotics and ongoing antimicrobial stewardship.[14]
Methicillin-resistant S aureus remains a very uncommon cause of uncomplicated cystitis or

pyelonephritis.[15]
Pathophysiology
The most common route of infection in females is via an ascending pathway. Colonisation of the vagina
may occur first, then ascends into the urinary tract.[16] Ascending UTI is amplified by factors that promote
the introduction of bacteria at the urethral meatus and by iatrogenic means. Stasis of bladder urine impairs
the defence against infection provided by bladder emptying.[17] While the mechanical model of ascending
infection explains the means of onset of bacteriuria, host and bacterial factors explain the variability of risk for
UTI among women.
Type 1 pili may enhance bacterial adherence and seem to be instrumental in the pathogenesis of bacterial
cystitis.[18] Type 1 piliated Escherichia coli bind in greater numbers to vaginal fluid from women with E
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Urinary tract infections in women Basics
coli vaginal colonisation. Alkalinisation of vaginal fluid (as occurs post-menopausally) results in augmented
binding. Conversely, acidification of vaginal fluid pH by application of topical oestrogen compounds may
reduce recurrence of UTI in post-menopausal women.[19]
BASICS
Classification
Uncomplicated or complicated[1] [2]
Uncomplicated UTIs include acute cystitis occurring in otherwise healthy, non-pregnant women without
functional or anatomical urinary tract abnormalities.
Complicated UTIs include infections in patients with functional or structural impairments that reduce the
efficacy of antimicrobial therapy. This may be abnormalities of the genitourinary tract, an underlying condition
that interferes with host defence, or nosocomial or multidrug resistant pathogens. The involvement of the
kidneys (pyelonephritis) or UTIs occurring in pregnancy are also considered complicated UTIs.
Acute or recurrent[1] [2]

A UTI can be acute or recurrent. Acute UTIs are infections causing acute symptoms in the presence of
infected urine. Some women may have infrequent or isolated UTIs, while other women may have frequent
recurrent infections. Recurrent UTI is defined as 2 separate culture-proven episodes of acute UTIs and
associated symptoms within 6 months, or >3 UTIs in 12 months.
Re-infection/bacterial persistence
Re-infection can occur with varying time intervals or causative organisms.
Bacterial persistence is persistent infection with the same organism, usually because the nidus of infection
has not been eradicated.
This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Sep 04, 2019.
5
Urinary tract infections in women Prevention
Primary prevention
The mainstay of UTI prevention is avoidance of known risk factors. Women who are prone to UTIs should
avoid spermicidal products. Vaginal oestrogen therapy in post-menopausal women with symptomatic UTIs
should be considered as a preventative measure.
Screening
Pregnancy
Pregnant women should be screened for asymptomatic bacteriuria,[6] as the presence of bacteriuria has
been associated with higher rates of pyelonephritis and premature labour in pregnancy.[46] Screening for
and treatment of asymptomatic bacteriuria is not recommended in non-pregnant women.[6] [42]
Pre-surgery
Bacteriuria should be treated before surgeries involving an increased risk and consequence of infection from
PREVENTION
UTI, such as urological procedures at risk of breaching the mucosal lining (e.g., urinary stone surgery).[6]
Secondary prevention
Prevention of UTI includes reduction of modifiable risk factors, such as avoidance of spermicide products.
In patients with recurrent UTI, the risk of UTI can be reduced with low-dose antimicrobial prophylaxis, single-
dose antimicrobial therapy before or after sexual intercourse, or self-initiated therapy. In post-menopausal
women, the incidence of recurrence may be decreased with topical vaginal oestrogen cream.
There is little evidence to support hydration and urination soon after sexual intercourse for the prevention of
UTIs.[21]
There is conflicting evidence to support cranberry for the prevention of UTIs.[83] [84] [85] A 2012 Cochrane
review found no benefit with respect to reduction in number of infections,[86] whereas another meta-analysis
found that cranberry was associated with a protective effect.[87]
One contributing factor to the controversial clinical results obtained with cranberry is the often lacking
precise determination and authentication of the bioactive proanthocyanidin (PAC) of the A type
content.[88] Cranberry supplements (containing 36 mg PAC per daily dose) prevented postoperative
urinary tract infections in women undergoing benign gynaecological surgery involving urinary
catheterisation.[89] Other studies have shown a reduction in UTI burden with daily cranberry juice intake in
women with a recent history of UTI.[90]
If patients are interested in a non-antibiotic option for the prevention of UTI, they should be informed that 36
mg of PAC is the recommended effective dose for UTI prevention; however, doses may vary between brands
and the label should always be consulted.
Urinary tract infections in women Diagnosis
Case history
Case history #1
A 27-year-old, healthy, sexually active woman presents with pain on urination and recent onset of urinary
frequency and urgency. She has no costovertebral angle tenderness on examination.
Case history #2
A 74-year-old post-menopausal woman with diabetes mellitus presents with pain on urination and urinary
frequency. This is her fourth episode of symptomatic UTI. Her previous episodes were confirmed with
bacterial cultures.
Other presentations
Asymptomatic bacteriuria is a significant number of bacteria in the urine that occurs without the usual
symptoms of UTI. It is present in up to 5% of healthy, pre-menopausal women with prevalence increasing
with age such that by 80 years, 20% of healthy women resident in the community have asymptomatic
bacteriuria.[3] The prevalence of asymptomatic bacteriuria in nursing home patients is up to 50%.[4]
Asymptomatic bacteriuria usually does not need treatment.[5] Recommendations may differ for specific
populations (e.g., pregnancy, patients undergoing endourological procedures).[6]
Step-by-step diagnostic approach

Treatment can be initiated based on both symptomatic diagnosis and urinalysis result. Urine culture and
sensitivity confirms diagnosis and determines selection of appropriate antibiotics.[36] Quality standards and
guidelines should be considered when evaluating and treating suspected urinary tract infections.[37] [38]
DIAGNOSIS
Clinical evaluation
The probability of UTI in primary care settings in women with one or more symptoms of UTI (dysuria,
urinary urgency, urinary frequency, supra-pubic pain, back pain, or gross haematuria) is about 50%.[34]
Other symptoms suggestive of upper tract involvement (such as pyelonephritis) include fever and/or
costovertebral tenderness.
Dipstick analysis
Dipstick urinalysis is considered as the first diagnostic test in women with urinary tract symptoms. The
combination of positive nitrite and leukocyte esterase in the urine indicates a likely diagnosis of UTI.[34]
However, if the dipstick result is negative but the symptoms suggest a UTI, the probability of disease is
still relatively high.[34] [39] [40]
In the absence of an acute UTI, dipstick tests positive for blood require a microscopic urinalysis
to delineate between true microhaematuria (presence of >3 RBCs per high-power field on 2 urine
specimens) and haemoglobinuria (positive haem on dipstick in the absence of red blood cells).
Microhaematuria in the absence of UTI requires further evaluation to determine the aetiology.
7
Urine microscopy and culture
A midstream clean-catch urine specimen should be sent for culture in cases with atypical symptoms,
unexpected findings on urinalysis, suspected pyelonephritis, and women whose symptoms do not resolve
or whose symptoms recur within 2 to 4 weeks of treatment.[35] Culture can also be used to obtain pre-
treatment antibiotic sensitivities in women with a history of recent antimicrobial therapy, with symptoms >7
days, age >65 years, people with diabetes, or pregnant women.
Growth of a single uropathogen at a quantity as low as 100 colony-forming units per millilitre (CFU/mL)
may indicate a significant infection in a symptomatic woman that requires antibiotic treatment.[41] To
diagnose bacteriuria, decreasing the colony count to 1000 to 10,000 CFU/mL in symptomatic patients will
improve the sensitivity without significantly compromising specificity.[42]
A Gram stain can be used to confirm organism type and guide antibiotic selection in complicated UTI or
pyelonephritis.
Imaging
Uncomplicated UTI does not usually require radiological evaluation unless it is recurrent; imaging should,
in general, be reserved for those patients in whom conventional treatment has failed or who have
unusually severe or persistent symptoms.[43] Upper urinary tract abnormalities are not common with
bacterial cystitis in healthy women, and therefore the routine use of scans is not indicated.
Renal ultrasound and abdominal/pelvic computed tomography (CT) scan can be used to rule out upper
tract abnormalities, including kidney stone, hydronephrosis, renal abscess, or renal scarring.
Consider imaging for women with:
• Unexplained or persistent haematuria, obstructive symptoms, neurogenic bladder dysfunction, and

a history of urinary calculi, analgesic abuse, or diabetes mellitus
• A complicated UTI, to rule out structural abnormalities, tumour, or stone
• Recurrent UTI with breakthrough UTIs despite prophylaxis
DIAGNOSIS
• A persistent bacterial infection despite adequate treatment.

A CT scan of the retroperitoneum should be used to rule out renal or peri-renal abscess if symptoms do
not respond to antimicrobial therapy or if >7 days' duration.[17]
Cystoscopy
Cystoscopy can be used to visualise the bladder and rule out lower tract abnormalities such as a tumour,
bladder stone, foreign body, or diverticulum, and is indicated for the same reasons noted for ordering an
imaging study.
Post-void residual (PVR)

If urinary retention or incomplete bladder emptying is suspected after resolution of a current UTI, or in
someone with recurrent UTI, a PVR can be done to observe if the bladder is emptying normally. An
elevated PVR of >100 mL indicates that the patient is not emptying the bladder to completion, which may
promote infection and may be a predisposing factor to UTI. If abnormal emptying is observed, further
evaluation may be undertaken to investigate the cause.
Risk factors
Strong
sexual activity
• Sexual intercourse is the strongest risk factor.[20]
• Any lifetime sexual activity and any sexual activity during the past year are strongly associated with
recurrent UTI.[21]
spermicide use
• Spermicides, including nonoxynol-9, decrease vaginal lactobacilli, which facilitates vaginal Escherichia
coli colonisation and results in an increased risk of UTI.[22] [23]
• Even the relatively small amounts of spermicide coating condoms increases the risk of UTI.[24]
post-menopause
• The absence of oestrogen (consistent with urogenital atrophy, vaginal atrophy, and also known as
genitourinary syndrome of menopause) is a risk factor for UTIs.[25]
• Topical intra-vaginal oestrogen treatment reduces UTIs in post-menopausal women;[19] [26] [27]
oestrogenisation of the vaginal mucosa promotes lactobacilli colonisation, which reduces the presence
of uropathogens and thus the risk of UTIs. Conversely, systemic oral oestrogen therapy is not
associated with benefit related to reduction of recurrent UTIs,[27] and is not recommended over the
use of topical oestrogen therapy.[28]
• Sexual activity in post-menopausal women is less strongly associated with UTIs than in younger
women.
• Urinary incontinence and oestrogen supplementation have also been associated with UTI in older
women, although the reasons for this are incompletely understood.[29]
positive family history of UTIs

• Having a mother with a history of UTIs is associated with a 2- to 4-fold increase in risk of recurrent
DIAGNOSIS
UTI.[21]
history of recurrent UTI

• A well-established risk factor.[30]
presence of a foreign body

• Any indwelling catheter or any foreign body (stone, suture, surgical material, or exposed polypropylene
mesh from pelvic surgery) significantly increases risk for UTI.
• Foreign bodies serve as nidus for UTIs and interfere with a person's ability to clear a UTI.
• Bacteriuria occurs in the presence of indwelling or intermittent catheters, and asymptomatic bacteriuria
does not require treatment. When a symptomatic UTI is present in a patient with a catheter or stent,
catheter or stent change should be strongly considered.[1]
Weak
insulin-treated diabetes
• Considered a more predominant risk factor in older women.[31]
9
high lifetime number of UTIs
• Considered a more predominant risk factor in older women.[31]
recent antibiotics
• The recent use of certain antimicrobials may predispose women to UTIs through their effects on the
genitourinary microbiome.[32] [33]
poor bladder emptying

• Due to either poor detrusor muscle contraction or bladder outlet obstruction (e.g., secondary to pelvic
organ prolapse or a prior anti-incontinence procedure), can lead to urinary stasis, interfering with a
person's intrinsic ability to clear bacteriuria.
increasing age
• Ten percent of women aged 70 years have UTIs.[34] [35]
History & examination factors

Key diagnostic factors
presence of risk factors (common)
• Key risk factors include sexual activity, spermicide use, positive family history, history of recurrent UTI,
presence of a foreign body (such as a bladder stone or a stitch from previous pelvic surgery), and
post-menopausal urogenital atrophy.
dysuria (common)
• Four symptoms and one sign (including dysuria, frequency, haematuria, back pain, costovertebral
angle tenderness) significantly increases the probability of UTI.[34]
urinary frequency (common)

DIAGNOSIS
haematuria (common)
back/flank pain (common)

costovertebral angle tenderness (common)

• When costovertebral angle tenderness is present, a diagnosis of pyelonephritis should be considered.
fever (uncommon)
• Part of clinical syndrome of pyelonephritis.
Other diagnostic factors

urinary urgency (common)
• Common symptom. Can also be a sign of an over-active bladder.
supra-pubic pain and tenderness (common)

• If present, increases the probability of an UTI.[44]
Diagnostic tests
1st test to order
Test Result
urine dipstick nitrite and leukocyte
esterase positive
• Most effective in UTI with high bacterial count.
• Diagnosis better if used in combination with other tests.
• If the dipstick result is negative but the symptoms suggest a UTI, the
probability of disease is still relatively high.[34] [39] [40]
urine microscopy bacteria, WBC, possibly
red blood cell
• Used to confirm organism type and guide antibiotic selection in
complicated UTI or pyelonephritis.
urine culture and sensitivity growth of >10# CFU/mL
• This is the most specific and sensitive test.
• If the result is <10⁵ colony-forming units per millilitre (CFU/mL) and
pyuria is present (>20 WBC/mm³) or the patient is symptomatic, the
result may still be considered positive.[35]
Other tests to consider
DIAGNOSIS
Test Result
post-void residual (PVR) >100 mL
• Indicated if urinary retention or incomplete bladder emptying is
suspected.
• An elevated PVR of >100 mL indicates that the patient is not
emptying the bladder to completion, which may be a predisposing
factor to UTI.
renal ultrasound kidney stone;
hydronephrosis; renal
• Only in patients in whom conventional treatment has failed or who
abscess; renal scarring
have unusually severe or persistent symptoms.[43]
abdominal/pelvic CT scan kidney or bladder stone;
renal abscess
• CT scan of the retroperitoneum can be used to rule out renal or peri-
renal abscess if symptoms do not respond to antimicrobial therapy
after >7 days' duration.
cystoscopy tumour; bladder
stone; foreign body;
• Used to visualise the bladder and rule out lower tract abnormalities.
diverticulum
• Indicated only in patients in whom conventional treatment has failed
or who have unusually severe or persistent symptoms.[43]
11
Differential diagnosis
Condition Differentiating signs / Differentiating tests

symptoms
Over-active bladder • Urinary urgency and • Negative urine dipstick,
frequency in the absence of microscopic urinalysis, and
a UTI. urine culture.
Urothelial carcinoma • Microscopic and/or gross • Positive urine cytology.

of the bladder or upper haematuria in the absence of Tumour seen on cystoscopy
urinary tract a UTI. or upper tract imaging.
Non-infectious urethritis • Dysuria, possibly with • Negative urine dipstick,

irritative voiding symptoms, microscopic urinalysis, and
in the absence of a UTI. urine culture.
Foreign body in bladder • Recurrent or unresolved UTI. • Foreign body (e.g., stone,
stitch from prior pelvic
surgery) visualised on
imaging or cystoscopy.
Vaginitis due to Candida • Presence of vaginal • Negative urine dipstick,

discharge and/or vaginal microscopic urinalysis, and
irritation. urine culture; positive vaginal
cultures.
• Direct examination yields
budding yeasts and hyphae
- the use of potassium
hydroxide enhances the
recovery of these fungal
elements; yeasts provoke
a large white blood cell
response with a negative
amine test. Normal vaginal
DIAGNOSIS
flora will be present.
Vaginitis due to • Presence of vaginal • Negative urine dipstick,

trichomonas discharge and/or vaginal microscopic urinalysis, and
irritation. urine culture; positive vaginal
cultures.
• Direct examination
commonly reveals motile
parasite with its flagella
whipping back and forth; the
infection is associated with
large numbers of white cells
with a positive amine test
and the absence of normal
vaginal flora.
Bacterial vaginosis and • Presence of vaginal • Negative urine dipstick,

cervicitis due to Neisseria discharge and/or vaginal microscopic urinalysis, and
gonorrhoeae, Chlamydia irritation. urine culture.
trachomatis, or herpes • Positive vaginal cultures;
simplex positive DNA probe assay for
gonorrhoea and chlamydia.

symptoms
Interstitial cystitis • Pain associated with bladder • Symptoms with negative
(painful bladder filling as well as urinary urine cultures are
syndrome) urgency and frequency in the characteristic of interstitial
absence of a UTI or other cystitis.
aetiology. The course of the
disease is usually marked by
flare-ups and remissions.[45]
• Dyspareunia and supra-
pubic discomfort as well
as anterior vaginal wall
tenderness on examination.
Urethral diverticulum • May present with dysuria, • Characteristic radiographic

dyspareunia, and/or findings on voiding
dribbling. cystourethrography (peri-
• On physical examination, urethral fluid collection) or
a fluctuant urethral mass T2-weighted MRI (bright
as well as purulent meatal image in peri-urethral area).
discharge upon mass
compression may be noted.
Infected Skene gland cyst • May present with urethral • May be visualised on MRI.
pain, discharge, and/or
urgency and frequency.
Pelvic organ prolapse • May present with vaginal • Diagnosis is clinical.

bulge symptoms, pelvic • No evidence of infection in
fullness or pressure and/or urine studies.
voiding dysfunction.
Urethral cancer • May present with voiding • A urethral mass can be

symptoms or haematuria. visualised on cystoscopy and
• Urethral induration may confirmed by pathological
DIAGNOSIS
be noted on physical diagnosis of biopsy
examination. specimen.
Radiation cystitis • Hx of pelvic radiation. • Findings on cystoscopy

• May have voiding symptoms include diffuse erythema,
and/or haematuria. oedema, vascularity,
petechiae, and patches of
pallor.
Post-cyclophosphamide • Hx of cyclophosphamide • Diagnosed by cystoscopy

cystitis treatment. (diffuse erythema, oedema,
• Irritative voiding symptoms. vascularity, petechiae,
patches of pallor) and,
possibly, biopsy.
Atypical infections • May present with recurrent • Diagnosed by culture of

of lower urinary tract voiding symptoms or sterile atypical organisms.
(fungal, adenovirus, pyuria.
tuberculosis)
13

symptoms
Asymptomatic bacteriuria • This is not considered a UTI, • Bacteria and, occasionally,
but is present in up to 20% WBCs in the urine in
of healthy women,[6] and its the absence of urinary
prevalence is even higher in symptoms.
nursing home patients up to
50%.[4]
DIAGNOSIS
Urinary tract infections in women Treatment
Step-by-step treatment approach

The main goal of management is treatment of symptomatic UTI. Empirical treatment with antibiotics should
be guided by local bacterial susceptibilities and guidelines.[47] [14] Resistance rates higher than 15% to 20%
necessitate a change in antibiotic class.[42]
Uncomplicated UTI
Patients with an uncomplicated UTI are generally healthy women without functional or structural
abnormalities. In otherwise healthy, adult, non-pregnant women with acute uncomplicated bacterial
cystitis, a short course of antimicrobial therapy is usually sufficient.[42] [48] [49]
Nitrofurantoin is usually effective first-line therapy for uncomplicated cystitis in most women and is given
for 5 days.[1] [48] [50] Other recommended first-line choices include a 3-day course of trimethoprim/
sulfamethoxazole (TMP/SMX), or a single dose of fosfomycin.[1] [48]
In areas with a known high prevalence of resistance to TMP/SMX (>10% to 20%), or in patients who
have used TMP/SMX or similar spectrum antibiotics recently, short-course antimicrobial therapy with
a fluoroquinolone or a beta-lactam (e.g., amoxicillin/clavulanate) should be considered as second-line
therapy.[14] [1] [48] [51]
The Food and Drug Administration warns that fluoroquinolones are associated with disabling and
potentially permanent side effects involving tendons, muscles, joints, nerves, and the central nervous
system. Therefore, they recommend that fluoroquinolones should be reserved for patients who have no
alternative treatment options for uncomplicated UTIs as the risks generally outweigh the benefits in these
patients.[52]
In one randomised controlled trial, women with UTIs treated with ibuprofen recovered without any
antibiotics.[53] Initial symptomatic treatment can be discussed with women who may be willing to
avoid immediate antibiotics and who are prepared to accept a potentially higher burden of symptoms.
Symptomatic treatment combined with delayed antibiotic prescription using a drug with a low resistance
profile (e.g., nitrofurantoin) addresses the need to reduce antibiotic consumption while minimising the risk
of complications.[54]
Additionally, risk of collateral effects of antibiotics should be considered. Risk of Clostridium difficile has
been associated with high-risk antibiotics (clindamycin, carbapenems, cephalosporins, fluoroquinolones)
compared with lower-risk antibiotics (penicillins, macrolides, sulfonamides and trimethoprim,
tetracyclines).[55]
Complicated UTI
UTI may be complicated by factors that reduce the efficacy of antimicrobial therapy, such as structural or
functional abnormalities of the urinary tract, an underlying condition that interferes with host defence, and/
or by nosocomial or multidrug resistant pathogens. For complicated UTI, urine culture and antimicrobial
sensitivity is recommended and the choice of treatment should be based on confirmed sensitivities.
TREATMENT
Longer courses of oral antibiotics are generally used, compared with uncomplicated UTI.[1] Non-pregnant
women with febrile UTI can be successfully treated with a 7-day course of appropriate antibiotics.[56]
Women with a complicated UTI but mild symptoms can be treated on an outpatient basis with a
fluoroquinolone or TMP/SMX.[57] An oral beta-lactam (e.g., amoxicillin/clavulanate) is another alternative
15
when these agents cannot be used; however, beta-lactams have inferior efficacy and increasing
resistance rates.[1] [48]
Hospitalisation and parenteral antibiotics should be considered for women with fever, elevated white
blood cell (WBC) count, emesis, or volume depletion that are present in addition to typical UTI symptoms.
Examples of suitable parenteral antibiotic regimens include a fluoroquinolone (e.g., ciprofloxacin,
levofloxacin), an aminoglycoside (e.g., gentamicin) with or without ampicillin, an extended-spectrum
cephalosporin (e.g., ceftriaxone) with or without gentamicin, an extended-spectrum penicillin (e.g.,
piperacillin/tazobactam), or a carbapenem (e.g., meropenem). Choice depends on local resistance data
and susceptibility results.[1] [57]
If the patient has underlying hydronephrosis, then the aetiology of the hydronephrosis should be
evaluated and treated with prompt drainage. Likewise, if the patient has an underlying renal abscess, this
should be drained and treated. Finally, if a patient with a catheter or ureteral stent has a UTI, catheter or
stent change should be strongly considered.[1]
UTI in pregnancy
UTI occurring in pregnancy is also considered a complicated UTI. Empirical antibiotic treatment should be
considered for acute cystitis in pregnancy, with a culture requested to confirm sensitivities.
Physicians must consider the risk posed by particular antibiotics during pregnancy. Penicillins,
cephalosporins, and nitrofurantoin are considered to be safe in pregnancy; however, nitrofurantoin is not
recommended at term due to the risk of haemolytic anaemia in the baby. Trimethoprim/sulfamethoxazole
is not recommended in pregnancy. Aminoglycosides and fluoroquinolones should only be used in
pregnant women when the benefits of treatment outweigh the associated risks. The risks associated
with the use of aminoglycosides are mainly nephrotoxicity and ototoxicity; however, with appropriate
dosing and monitoring of serum trough levels, many specialists use these drugs in pregnancy as there
are data supporting their use.[58] There have been case reports of fetal toxicity when used in pregnancy,
so caution is advised. Previously, there were concerns about using fluoroquinolones in pregnancy due to
reports of arthropathy in animal studies; however, reports are rare in humans.[59] A specialist should be
consulted for guidance when selecting an appropriate antibiotic regimen in pregnant women. Pregnant
women should not be denied appropriate treatment for infections because untreated infections can
commonly lead to serious maternal and fetal complications.[60]
As with non-pregnant women, pregnant women with mild symptoms can be treated on an outpatient
basis. Oral antibiotic options include cephalexin, nitrofurantoin, or amoxicillin/clavulanate. Urine cultures
should be repeated 48 hours after completion of treatment to ensure that the infection has cleared.
Hospitalisation and parenteral antibiotics should be considered for pregnant women with fever, elevated
WBC count, emesis, or volume depletion that are present in addition to typical UTI symptoms. Examples
of suitable antibiotic regimens in pregnant women include an aminoglycoside (e.g., gentamicin) with or
without ampicillin, an extended-spectrum cephalosporin (e.g., ceftriaxone) with or without gentamicin,
an extended-spectrum penicillin (e.g., piperacillin/tazobactam), a carbapenem (e.g., meropenem),
or a fluoroquinolone (e.g., ciprofloxacin, levofloxacin). Choice depends on local resistance data and
TREATMENT
susceptibility results.[48]
If the patient has underlying symptomatic hydronephrosis, this should be treated. Usually conservative
management with analgesia, intravenous fluids, and antibiotics is sufficient in pregnancy. Hydronephrosis
is a common physiological condition in pregnancy and disappears rapidly after birth. Renal abscess is an
unusual finding in pregnancy. The underlying aetiology should be evaluated and treatment determined
based on this and clinical symptoms. Deferring treatment until after pregnancy may be considered.
Recurrent UTI
A recurrent UTI is defined as 2 separate culture-proven episodes of acute UTIs and associated symptoms
within 6 months, or 3 or more episodes in a 12-month period.[2]
The most common cause of recurrent UTI in women is re-infection, which may occur with varying time
intervals and causative organisms. Re-infection is usually unrelated to a remediable urinary abnormality
and does not require extensive urological evaluation. In contrast, women with bacterial persistence (same
organisms but closer time intervals) should be evaluated thoroughly. They may be cured by identification
and correction of a structural abnormality, such as a urethral diverticulum, or removal of a bacterial nidus
such as a kidney stone.
Antibiotic options for recurrent UTI include daily prophylactic low-dose antibiotics, post-coital prophylactic
antibiotics, or self-start therapeutic antibiotic therapy.[61]
Intravesicular instillation of a combination of sodium hyaluronate and chondroitin sulfate is being tried
and may be considered as a non-antibiotic option for UTI prophylaxis, but data are limited, and cost and
availability are limiting factors.[62]
The risk of UTI can be reduced with low-dose antimicrobial prophylaxis. A meta-analysis and systematic
review showed that long-term antibiotics reduced the risk of UTI recurrence by 24% in postmenopausal
women, with no statistically significant increase in risk of adverse events.[63] The decision to initiate
prophylaxis is usually based on clinical judgement and patient preference.
Self-diagnosis and self-initiation of therapy is appropriate for compliant women with a history of recurrent
UTI and low risk for sexually transmitted disease.[64] Self-initiated therapy involves the patient identifying
symptoms of infection and initiating treatment.[65] Urine cultures can be submitted at the time of UTI
symptoms to guide treatment.
Treatment of recurrent UTI in post-menopausal women includes intra-vaginal oestrogen, which restores
the normal vaginal flora and reduce the risk of vaginal colonisation by Escherichia coli. In women
with frequent recurrences, additional prophylaxis with nightly low-dose antibiotics may be helpful. In
a systematic review, antibiotics were the most efficacious therapy, but were associated with a higher
incidence of systemic side effects.[66] There are data to support the use vaginal oestrogen in prevention
of UTIs; however, it is inferior to continuous antibiotic suppression.[66] Oral systemic oestrogen is not
considered effective in prevention of recurrent UTI.
If sexual intercourse has a temporal relationship with UTI, post-coital therapy may be appropriate. Single-
dose antibiotic therapy after sexual intercourse has been shown to reduce the incidence of infection.[67]
Treatment details overview

TREATMENT
Please note that formulations/routes and doses may differ between drug names and brands, drug
formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
Acute ( summary )
17
Acute ( summary )
uncomplicated
without antibiotic 1st oral antibiotic therapy

resistance
with known or suspected 1st oral antibiotic therapy

antibiotic resistance
complicated suitable for outpatient

therapy: not pregnant
1st oral antibiotic therapy

therapy: pregnant
complicated requiring inpatient

1st intravenous antibiotic therapy
with structural or plus definitive treatment of underlying

functional abnormalities abnormality

therapy: pregnant
1st alternative intravenous antibiotic therapy
with structural or adjunct definitive treatment of underlying

Ongoing ( summary )
uncomplicated recurrent (3 or more
in 12 months): related to sexual
intercourse
pre-menopausal 1st post-coital antibiotic therapy
post-menopausal 1st intra-vaginal oestrogen therapy
plus post-coital antibiotic therapy

in 12 months): unrelated to sexual
intercourse
TREATMENT
pre-menopausal 1st low-dose prophylactic antibiotic
1st antibiotic self-treatment
Ongoing ( summary )
adjunct low-dose prophylactic antibiotic
adjunct antibiotic self-treatment
TREATMENT
19
Treatment options
Please note that formulations/routes and doses may differ between drug names and brands, drug
formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
Acute
uncomplicated
without antibiotic 1st oral antibiotic therapy

resistance
Primary options
» nitrofurantoin: 100 mg orally (modified-

release) twice daily for 5 days
OR
» trimethoprim/sulfamethoxazole: 160/800 mg
orally twice daily for 3 days
Secondary options
» fosfomycin: 3 g orally as a single dose
» Uncomplicated UTIs include acute cystitis

occurring in otherwise healthy, non-pregnant
women without functional or anatomical urinary
tract abnormalities.
» Nitrofurantoin is usually an effective first-line

therapy for cystitis in most women.[14] [1] [48]
» Other recommended choices include a 3-day

course of trimethoprim/sulfamethoxazole, or a
single dose of fosfomycin.[1] [48]
with known or suspected 1st oral antibiotic therapy
antibiotic resistance
Primary options
» ciprofloxacin: 250 mg orally twice daily for 3

days
OR
» levofloxacin: 250 mg orally once daily for 3

days
OR
» amoxicillin/clavulanate: 500 mg orally twice

TREATMENT
daily for 3 days

Dose refers to amoxicillin component.
» Uncomplicated UTIs include acute cystitis

occurring in otherwise healthy, non-pregnant
Acute
women without functional or anatomical urinary
tract abnormalities.
» A fluoroquinolone should be considered

if there is known resistance to the first-line
agents above, or for empirical therapy in areas
with a known high prevalence of resistance to
trimethoprim/sulfamethoxazole (TMP/SMX)
(>10% to 20%), or in patients who have used
TMP/SMX or similar spectrum antibiotics
recently.
» The US Food and Drug Administration warns

that fluoroquinolones are associated with
disabling and potentially permanent side effects
involving tendons, muscles, joints, nerves, and
the central nervous system. Therefore, they
recommend that fluoroquinolones should be
reserved for patients who have no alternative
treatment options for uncomplicated UTIs as the
risks generally outweigh the benefits in these
patients.[52]
» An oral beta-lactam is an alternative in

selected cases.[14] [1] [48]

Primary options
» ciprofloxacin: 500 mg orally twice daily for 7

days
OR
» levofloxacin: 750 mg orally once daily for 5

days
OR
orally twice daily for 7-14 days
Secondary options

daily for 7 days
TREATMENT
» Complicated UTIs include infections in patients

with functional or structural impairments that
reduce the efficacy of antimicrobial therapy. This
may be abnormalities of the genitourinary tract
or an underlying condition that interferes with
host defence. The involvement of the kidneys
21
Acute
(pyelonephritis) or UTI occurring in pregnancy
are also considered complicated UTIs.
» Urine culture and antimicrobial sensitivity is

recommended, and the choice of treatment
should be based on confirmed sensitivities.
Women with a complicated UTI but mild
symptoms can be treated on an outpatient
basis with a fluoroquinolone or trimethoprim/
sulfamethoxazole.[57] An oral beta-lactam
(e.g., amoxicillin/clavulanate) is another
alternative when these agents cannot be used;
however, beta-lactams have inferior efficacy and
increasing resistance rates.[1] [48]
» Longer courses of oral antibiotics are generally

used, compared with uncomplicated UTI.[1]
» Non-pregnant women with febrile UTI can

be successfully treated with a 7-day course of
appropriate antibiotics.[56]
» When a UTI is present in a patient with a

catheter or stent, catheter or stent change
should be strongly considered.[1]
therapy: pregnant

Primary options
» cefalexin: 500 mg orally twice daily for 10

days
OR

OR

daily for 7 days
» Complicated UTIs include infections in patients

with functional or structural impairments that
reduce the efficacy of antimicrobial therapy. This
may be abnormalities of the genitourinary tract
or an underlying condition that interferes with
TREATMENT
host defence. The involvement of the kidneys

(pyelonephritis) or UTI occurring in pregnancy
are also considered complicated UTIs.
» Pregnant women with mild symptoms can be

treated on an outpatient basis.
Acute
» Urine culture and antimicrobial sensitivity is
recommended, and the choice of treatment
should be based on confirmed sensitivities.
Oral antibiotic options include cefalexin,
nitrofurantoin, or amoxicillin/clavulanate.
Penicillins, cephalosporins, and nitrofurantoin
are considered to be safe in pregnancy;
however, nitrofurantoin is not recommended at
term due to the risk of haemolytic anaemia in the
baby.
» Longer courses or higher doses of oral

antibiotics are generally used, compared with
uncomplicated UTI.
» When a UTI is present in a patient with a

catheter or stent, catheter or stent change
should be strongly considered.[1]
» Empirical antibiotic treatment should be

considered for acute cystitis in pregnancy, with a
urine culture requested to confirm sensitivities.
» Repeat the urine culture 48 hours after

completion of treatment.
complicated requiring inpatient 1st intravenous antibiotic therapy

Primary options
» gentamicin: 1 to 1.5 mg/kg intravenously

every 8 hours for 7-14 days; or 5-7 mg/kg
intravenously once daily for 7-14 days
OR
» ceftriaxone: 1-2 g intravenously once daily

for 10-14 days
OR
» ampicillin: 0.5 to 2 g intravenously every 6

hours for 10-14 days
-and-
OR
TREATMENT

for 10-14 days
-and-
23
Acute
OR
» ciprofloxacin: 400 mg intravenously every

12 hours for 7-14 days
OR
» levofloxacin: 750 mg intravenously once

daily for 5 days; or 250 mg intravenously
once daily for 10 days
OR
» meropenem: 500 mg intravenously every 8

OR
» piperacillin/tazobactam: 3.375 g
intravenously every 6 hours for 10-14 days
Dose consists of 3 g of piperacillin plus 0.375
g of tazobactam.
» Hospitalisation and parenteral antibiotics

should be considered for women with fever,
elevated WBC count, emesis, or volume
depletion that are present in addition to typical
UTI symptoms. When a UTI is present in a
patient with a catheter or stent, catheter or stent
change should be strongly considered.[1]
» Parenteral antibiotics can be given until clinical

improvement and then, as condition improves,
equivalent oral antibiotics can be given for the
remainder of the course.
» Examples of suitable parenteral antibiotic

regimens include a fluoroquinolone (e.g.,
ciprofloxacin, levofloxacin), an aminoglycoside
(e.g., gentamicin) with or without ampicillin,
an extended-spectrum cephalosporin (e.g.,
ceftriaxone) with or without gentamicin,
an extended-spectrum penicillin (e.g.,
piperacillin/tazobactam), or a carbapenem (e.g.,
meropenem).[1] [57] Choice depends on local
resistance data and susceptibility results.
TREATMENT
» The US Food and Drug Administration warns

that fluoroquinolones are associated with
disabling and potentially permanent side effects
involving tendons, muscles, joints, nerves, and
the central nervous system. Therefore, they
Acute
recommend that they should be reserved for use
in patients who have no alternative treatment
options, and that use should be limited in the
treatment of uncomplicated UTIs. It is essential
that both health care providers and patients
are aware of these risks and make an informed
decision about their use.[52]
with structural or plus definitive treatment of underlying
Treatment recommended for ALL patients in
selected patient group
» If the patient has hydronephrosis, then the
aetiology of the hydronephrosis should be
evaluated and treated.
» Likewise, if the patient has a renal abscess,

this should be drained and treated.
therapy: pregnant
complicated requiring inpatient 1st alternative intravenous antibiotic therapy

therapy: pregnant
Primary options

OR

for 10-14 days
OR
» ampicillin: 0.5 to 2 g intravenously every 6

-and-
OR

for 10-14 days
-and-
TREATMENT
OR
25
Acute
» meropenem: 500 mg intravenously every 8
OR
» piperacillin/tazobactam: 3.375 g
intravenously every 6 hours for 10-14 days
Dose consists of 3 g of piperacillin plus 0.375
g of tazobactam.
Secondary options
» ciprofloxacin: 400 mg intravenously every

12 hours for 7-14 days
OR
» levofloxacin: 750 mg intravenously once

daily for 5 days; or 250 mg intravenously
once daily for 10 days
» Hospitalisation and parenteral antibiotics

should be considered for pregnant women with
fever, elevated WBC count, emesis, or volume
depletion that are present in addition to typical
UTI symptoms. When a UTI is present in a
patient with a catheter or stent, catheter or stent
change should be strongly considered.[1]
» Parenteral antibiotics can be given until clinical

improvement and then, as condition improves,
equivalent oral antibiotics can be given for the
remainder of the course.
» Pregnant women should not be denied

appropriate treatment for infections because
untreated infections can commonly lead to
serious maternal and fetal complications.[60]
» Physicians must consider the risk posed

by particular antibiotics during pregnancy.
Penicillins and cephalosporins are considered
to be safe in pregnancy. Aminoglycosides
and fluoroquinolones should only be used in
pregnant women when the benefits of treatment
outweigh the associated risks. The risks
associated with the use of aminoglycosides are
mainly nephrotoxicity and ototoxicity; however,
with appropriate dosing and monitoring of serum
trough levels, many specialists use these drugs
in pregnancy as there are data supporting their
TREATMENT
use.[58] There have been case reports of fetal

toxicity when used in pregnancy, so caution
is advised. Previously, there were concerns
about using fluoroquinolones in pregnancy
due to reports of arthropathy in animal studies;
however, reports are rare in humans.[59] A
Acute
specialist should be consulted for guidance
when selecting an appropriate antibiotic regimen
in pregnant women.
» Examples of suitable antibiotic regimens in

pregnant women include an aminoglycoside
(e.g., gentamicin) with or without ampicillin,
an extended-spectrum cephalosporin (e.g.,
ceftriaxone) with or without gentamicin, an
extended-spectrum penicillin (e.g., piperacillin/
tazobactam), a carbapenem (e.g., meropenem),
or a fluoroquinolone (e.g., ciprofloxacin,
levofloxacin). Choice depends on local
resistance data and susceptibility results.[48]
with structural or adjunct definitive treatment of underlying
Treatment recommended for SOME patients in
» If the patient has symptomatic hydronephrosis,
this should be treated. Usually conservative
management with analgesia, intravenous
fluids, and antibiotics is sufficient in pregnancy.
Hydronephrosis is a common physiological
condition in pregnancy and disappears rapidly
after birth.
» Renal abscess is an unusual finding in

pregnancy. The underlying aetiology should be
evaluated and treatment determined based on
this and clinical symptoms. Deferring treatment
until after pregnancy may be considered.
Ongoing
in 12 months): related to sexual
intercourse
pre-menopausal 1st post-coital antibiotic therapy

Primary options

release) as a single dose
OR
» trimethoprim: 100 mg orally as a single

TREATMENT
dose
OR
orally as a single dose
27
Ongoing
» Single-dose antibiotic therapy after sexual
intercourse has been shown to reduce the
incidence of infection.[67] The single dose
should be taken as soon as possible after sexual
intercourse.
Primary options
» estradiol vaginal: (cream 0.01%) insert 1 g

into the vagina twice weekly at night
OR
» estradiol vaginal: (vaginal tablets) 10

micrograms (1 tablet) into the vagina twice
weekly at night
» Local oestrogen therapy restores the normal

vaginal flora and reduces the risk of vaginal
colonisation by Escherichia coli. May be used in
post-menopausal women who are not taking oral
oestrogen.
» Systemic oestrogen therapy is not

recommended over the use of topical oestrogen
therapy when symptoms are localised to the
urogenital tract, given the benefit of reduced
oestrogen absorption when topical agents are
used.[28]
plus post-coital antibiotic therapy
Treatment recommended for ALL patients in
Primary options
» nitrofurantoin: 100 mg orally (modifed-

release) as a single dose
OR
» trimethoprim: 100 mg orally as a single

dose
OR
orally as a single dose
» Single-dose antibiotic therapy after sexual

TREATMENT
intercourse has been shown to reduce the

incidence of infection.[67] The single dose
should be taken as soon as possible after sexual
intercourse.
Ongoing
in 12 months): unrelated to sexual
intercourse
pre-menopausal 1st low-dose prophylactic antibiotic

Primary options

release) once daily at bedtime
OR
» trimethoprim: 100 mg orally once daily at

bedtime
OR
orally once daily at bedtime
» The risk of UTI can be reduced with low-dose

antimicrobial prophylaxis. In a systematic review,
antibiotics were the most efficacious therapy,
but were associated with a higher incidence
of systemic side effects.[66] The decision to
initiate prophylaxis is usually based on clinical
judgement and patient preference.
» If, during therapy, the woman experiences a

symptomatic infection, therapeutic dosing with
another agent should be instituted, followed by
re-instituting the prophylaxis regimen.
1st antibiotic self-treatment
Primary options

OR
OR
» Self-diagnosis and self-initiation of therapy

TREATMENT
is appropriate for treatment-adherent women

with a history of recurrent cystitis and low
risk for sexually transmitted disease.[64]
Self-initiated therapy involves the patient
29
Ongoing
identifying symptoms of infection and initiating
treatment.[65]
Primary options
» estradiol vaginal: (vaginal tablets) 10

micrograms (1 tablet) into the vagina twice
weekly at night
OR
» estradiol vaginal: (cream 0.01%) insert 1 g

into the vagina twice weekly at night
» Local oestrogen therapy restores the normal

vaginal flora and reduces the risk of vaginal
colonisation by Escherichia coli. May be used in
post-menopausal women who are not taking oral
oestrogen.
» Systemic oestrogen therapy is not

recommended over the use of topical oestrogen
therapy when symptoms are localised to the
urogenital tract, given the benefit of reduced
oestrogen absorption when topical agents are
used.[28]
adjunct low-dose prophylactic antibiotic
Primary options

release) once daily at bedtime
OR
» trimethoprim: 100 mg orally once daily at

bedtime
OR
orally once daily at bedtime
» The risk of UTI can be reduced with low-dose

antimicrobial prophylaxis. In a systematic review,
antibiotics were the most efficacious therapy,
but were associated with a higher incidence
TREATMENT
of systemic side effects.[66] The decision to

initiate prophylaxis is usually based on clinical
judgement and patient preference.
» If, during therapy, the woman experiences a

symptomatic infection, therapeutic dosing with
Ongoing
another agent should be instituted, followed by
re-instituting the prophylaxis regimen.
adjunct antibiotic self-treatment
Primary options

OR
OR
» Self-diagnosis and self-initiation of therapy

is appropriate for treatment-adherent women
with a history of recurrent cystitis and low
risk for sexually transmitted disease.[64]
Self-initiated therapy involves the patient
identifying symptoms of infection and initiating
treatment.[65]
TREATMENT
31
Emerging
Meropenem/vaborbactam
Meropenem has been combined with vaborbactam, a novel beta-lactamase inhibitor, to treat infections
caused by bacteria resistant to currently available carbapenems.[68] The US Food and Drug Administration
(FDA) has approved the drug for the treatment of adults with complicated UTI, including pyelonephritis. The
European Medicines Agency has also recommended approval in patients with complicated UTIs.
Pla zomicin
Plazomicin is a next-generation aminoglycoside designed to evade all clinically relevant aminoglycoside-
modifying enzymes, the main mechanism of aminoglycoside resistance.[69] [70] It has been approved by the
FDA for the treatment of patients 18 years of age or older with complicated UTIs, including pyelonephritis,
that are caused by certain Enterobacteriaceae in patients who have limited or no alternative treatment
options.
Vaccines
Vaccines against Escherichia coli and other uropathogens are a promising emerging treatment. Mucosal
and parenteral vaccines targeted at E coli and other uropathogens are being investigated.[71] [72] [73] [74]
Vaccines targeted at E coli are not yet available for clinical use.
Lactobacillus
Vaginal lactobacilli are an important host defence against UTI. In healthy pre-menopausal women, the
vaginal environment is acidic, with Lactobacillus species as the predominant bacteria. Studies to evaluate
the probiotic capacity of Lactobacillus species administered by the vaginal route have been carried out in
women with UTIs, with mixed but promising results.[75] A study showed that oral daily lactobacillus may be
as effective as daily trimethoprim/sulfamethoxazole in preventing infections in patients with recurrent UTI.[76]
Currently there is no reliable product for urogenital application of lactobacillus to prevent UTIs.[77] [78]
D-mannose
D-mannose is a simple sugar that may hinder bacterial adhesion to the urothelium. Small studies have
looked at D-mannose as a potential UTI prevention strategy.[79] [80] More studies are needed to determine
whether D-mannose can be an effective aid in acute cystitis symptom management and/or as a successful
prophylactic agent in a selected population.
TREATMENT
Urinary tract infections in women Follow up
Recommendations
Monitoring
FOLLOW UP
Routine follow-up is not required for patients with episodes of uncomplicated UTI who receive
antimicrobial treatment and experience resolution of symptoms.
Consider periodic renal function monitoring for patients with a history of complicated UTI.
Patient instructions
The patient should be advised to seek follow-up evaluation and treatment if symptoms recur or do not
resolve.
Complications
Complications Timeframe Likelihood

sepsis short term low
A combination of host and organism factors may be causes. Host factors include multiple medical
problems, indwelling catheters, and/or malnutrition. In many cases, urosepsis is linked to specific
complicating factors (e.g., obstruction, abscesses, foreign bodies, stones) in the urinary tract. Organism
factors include virulence factors and previous antibiotic treatments.[81]
Sepsis requires monitoring in an intensive care unit. Important steps include removal of precipitating
factors, maintenance of haemodynamic and nutritional parameters, and appropriate antibiotic treatment.
renal and peri-renal abscess short term low
Renal abscess is a pyogenic infection of the renal parenchyma. Many renal abscesses are due to gram-
negative bacteria and are believed to be related to an ascending infection caused by tubular obstruction
from prior infection or stones.
Symptoms may be vague and include fever, chills, and abdominal or flank pain. Patients with a history
of complicated UTI are at risk. UTIs associated with stasis, calculi, pregnancy, neurogenic bladder, and
diabetes may predispose patients to abscess formation.[82]
acute kidney injury short term low
May be the result of a severe complicated infection, related to antibiotic treatment, or associated with
multi-organ failure from sepsis. Medication doses may need to be adjusted. Nephrotoxic agents should be
avoided.
33
Urinary tract infections in women Follow up
Complications Timeframe Likelihood

emphysematous pyelonephritis variable low
FOLLOW UP
People with diabetes are at risk of this acute necrotising renal infection, in which micro-organisms (most
commonly Escherichia coli ) produce carbon dioxide by fermenting sugar. This disease is uncommon,
even among people with diabetes.
Emphysematous pyelonephritis most commonly occurs in immunocompromised older people.
Radiographic indicators are intra-parenchymal or supra-renal gas on plain x-ray.
Treatment includes broad-spectrum antibiotics and aggressive blood glucose monitoring and control.
If the affected renal tract is obstructed, this should be rapidly relieved by percutaneous drainage or, if
unresponsive to conservative measures, consideration should be given to a nephrectomy.
xanthogranulomatous pyelonephritis (XGP) variable low
XGP is a rare end-stage result of urinary obstruction and UTI. Proteus species are commonly involved
and are usually similar to the organisms associated with stone formation and chronic inflammation. CT
scan is the most useful imaging tool and demonstrates a large reniform mass with dilated calyces and
abscesses.
This disease is called the 'great imitator', as common symptoms (flank pain, fever, chills) mimic more
benign infections and the disease is often radiographically perceived to be neoplastic.
Treatment consists of surgical removal of all involved renal tissue, which usually involves a nephrectomy.
Prognosis
Uncomplicated UTI
Prognosis for uncomplicated UTI in women is excellent. With appropriate antimicrobial treatment and
resolution of symptoms, there is unlikely to be long-term sequelae.
Complicated UTI
Prognosis for complicated UTI is very good. With appropriate diagnosis and antimicrobial treatment,
infections can be managed effectively. Impairment of renal function is a rare, but possible, complication of
complicated UTI. Timely diagnosis and treatment is important for prevention of such complications.
Urinary tract infections in women Guidelines
Diagnostic guidelines
Europe
Guidelines on urological infections

Published by: European Association of Urology Last published: 2019
Diagnosis of urinary tract infections. Quick reference tool for primary care:
for consultation and local adaptation
Published by: Public Health England Last published: 2019
Management of suspected bacterial urinary tract infection in adults: a

national clinical guideline
Published by: Scottish Intercollegiate Guidelines Network Last published: 2012
GUIDELINES
North America
ACR Appropriateness Criteria: acute pyelonephritis

Published by: American College of Radiology Last published: 2018
ACR Appropriateness Criteria: recurrent lower urinary tract infections in

women
ACR Appropriateness Criteria: hematuria

Treatment guidelines
Europe
Guidelines on urological infections

Published by: European Association of Urology Last published: 2019
Urinary tract infection (lower): antimicrobial prescribing

Published by: National Institute for Health and Care Excellence Last published: 2018
Pyelonephritis (acute): antimicrobial prescribing

Urinary tract infection (recurrent): antimicrobial prescribing

35
Urinary tract infections in women Guidelines
Europe
Urinary tract infection (catheter-associated): antimicrobial prescribing

Urinary tract infections in adults

Management of suspected bacterial urinary tract infection in adults: a

national clinical guideline
Published by: Scottish Intercollegiate Guidelines Network Last published: 2012
International
International clinical practice guidelines for the treatment of acute

GUIDELINES
uncomplicated cystitis and pyelonephritis in women

Published by: Infectious Diseases Society of America; European Last published: 2011
Society of Clinical Microbiology and Infectious Diseases
North America
Asymptomatic bacteriuria
Published by: Infectious Diseases Society of America Last published: 2019
Recurrent Uncomplicated Urinary Tract Infections in Women: AUA/CUA/SUFU

Guideline
Published by: American Urological Association, Canadian Urological Last published: 2019
Association, Society of Urodynamics, Female Pelvic Medicine &
Urogenital Reconstruction
Recurrent urinary tract infection

Published by: Society of Obstetricians and Gynaecologists of Canada Last published: 2010 (re-
affirmed 2017)
Treatment of urinary tract infections in non-pregnant women

Published by: American Congress of Obstetricians and Gynecologists Last published: 2008 (re-
affirmed 2016)
Urinary tract infections in women References
Key articles
• European Association of Urology. Guidelines on urological infections. 2019 [internet publication]. Full
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43
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Contributors:
// Authors:
Una J. Lee, MD
Female Pelvic Medicine and Reconstructive Surgery
Section of Urology and Renal Transplantation, Virginia Mason Medical Center, Seattle, WA
DISCLOSURES: UJL declares that she has no competing interests.
// Acknowledgements:
Dr Una J. Lee would like to gratefully acknowledge Dr Elliot Blau for his contribution to this monograph, and
Dr Bhavin N. Patel and Dr Howard B. Goldman, previous contributors to this topic.
DISCLOSURES: EB, BNP, and HBG declare that they have no competing interests.
// Peer Reviewers:
Priyanka Sharma, MD
Associate Staff
Cleveland Clinic Foundation, Cleveland, OH
DISCLOSURES: PS declares that she has no competing interests.
Timothy J. Benton, MD
Associate Residency Director
Texas Tech University Health Sciences Center, Amarillo, TX
DISCLOSURES: TJB declares that he has no competing interests.
Paul Lit tle, BA (Oxon), MBBS, MRCP, MSc, FRCGP, MD

Professor of Primary Care Research
Community Clinical Sciences Division, University of Southampton, Southampton, UK
DISCLOSURES: PL declares that he has no competing interests.

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Last updated: Sep 04, 2019

◊ Can be clinically categorised into uncomplicated/complicated, acute, or recurrent.

◊ Escherichia coli is the most common organism in uncomplicated infections.

◊ Costovertebral angle tenderness together with fever suggests pyelonephritis.

Worldwide, infections caused by gram-negative strains (e.g., E coli , Enterobacteriaceae, Ps aeruginosa

Methicillin-resistant S aureus remains a very uncommon cause of uncomplicated cystitis or

Acute or recurrent[1] [2]

Step-by-step diagnostic approach

Consider imaging for women with:

• Unexplained or persistent haematuria, obstructive symptoms, neurogenic bladder dysfunction, and

• A persistent bacterial infection despite adequate treatment.

Post-void residual (PVR)

positive family history of UTIs

history of recurrent UTI

presence of a foreign body

poor bladder emptying

History & examination factors

urinary frequency (common)

back/flank pain (common)

costovertebral angle tenderness (common)

Other diagnostic factors

supra-pubic pain and tenderness (common)

Other tests to consider

Condition Differentiating signs / Differentiating tests

Urothelial carcinoma • Microscopic and/or gross • Positive urine cytology.

Non-infectious urethritis • Dysuria, possibly with • Negative urine dipstick,

Vaginitis due to Candida • Presence of vaginal • Negative urine dipstick,

flora will be present.

Vaginitis due to • Presence of vaginal • Negative urine dipstick,

Bacterial vaginosis and • Presence of vaginal • Negative urine dipstick,

Condition Differentiating signs / Differentiating tests

Urethral diverticulum • May present with dysuria, • Characteristic radiographic

Pelvic organ prolapse • May present with vaginal • Diagnosis is clinical.

Urethral cancer • May present with voiding • A urethral mass can be

Radiation cystitis • Hx of pelvic radiation. • Findings on cystoscopy

Post-cyclophosphamide • Hx of cyclophosphamide • Diagnosed by cystoscopy

Atypical infections • May present with recurrent • Diagnosed by culture of

Condition Differentiating signs / Differentiating tests

Step-by-step treatment approach

Treatment details overview

without antibiotic 1st oral antibiotic therapy

with known or suspected 1st oral antibiotic therapy

complicated suitable for outpatient

1st oral antibiotic therapy

complicated suitable for outpatient

1st oral antibiotic therapy

complicated requiring inpatient

1st intravenous antibiotic therapy

with structural or plus definitive treatment of underlying

complicated requiring inpatient

1st alternative intravenous antibiotic therapy

with structural or adjunct definitive treatment of underlying

pre-menopausal 1st post-coital antibiotic therapy

post-menopausal 1st intra-vaginal oestrogen therapy

plus post-coital antibiotic therapy

uncomplicated recurrent (3 or more

pre-menopausal 1st low-dose prophylactic antibiotic

1st antibiotic self-treatment

post-menopausal 1st intra-vaginal oestrogen therapy

adjunct antibiotic self-treatment

without antibiotic 1st oral antibiotic therapy