Complicated Urinary Tract Infection

Chapter: Complicated Urinary Tract Infection
McMaster Section Editor(s): Mark Loeb
Section Editor(s) in Interna Szczeklika: Franciszek Kokot, Robert Drabczyk
McMaster Author(s): Dominik Mertz
Author(s) in Interna Szczeklika: Jan Duława, Robert Drabczyk
Additional Information

Clinical Features And Diagnosis Top

The most frequently observed factors contributing to the diagnosis of complicated urinary tract infection (UTI) include male sex, diabetes mellitus, pregnancy, nephrolithiasis, and urinary obstruction.

Clinical features range from mild cystitis to urosepsis. In each case of a diagnosed or suspected complicated UTI, perform urinalysis, urine cultures, and blood biochemical tests to assess kidney function. Order blood cultures in all febrile hospitalized patients. Consider ultrasonography and abdominal radiographs in patients in whom it is necessary to exclude nephrolithiasis and urinary obstruction. Indications for additional imaging studies: suspected renal and perinephric complications of UTI (see Complications of Urinary Tract Infections), other coexisting pelvic or abdominal abnormalities, previously diagnosed urinary tract abnormalities that have contributed to the complicated UTI.

Treatment Top

1. Depending on the intensity of symptoms and the presence of comorbidities, the patient may either be treated as an outpatient or be admitted to the hospital. Potential indications for hospital admission: urinary tract abnormalities, immunocompromised patients, renal failure, serious comorbidities, other factors as in uncomplicated acute pyelonephritis.

2. Urologic intervention is the mainstay of treatment in the setting of an underlying obstruction. The key objective is to correct potential abnormalities in the urinary tract; in such cases antimicrobial treatment is only an adjunctive therapy.

3. Empiric treatment of complicated UTI as in uncomplicated acute pyelonephritis. If the empiric treatment is ineffective and microbiology results are unavailable, start a broad-spectrum antimicrobial agent active against Pseudomonas spp (eg, piperacillin + tazobactam, ceftazidime, or a carbapenem). Selection of oral antibiotics and duration of treatment as in uncomplicated acute pyelonephritis.

4. Outpatient treatment as in uncomplicated pyelonephritis.

5. Treatment in young men with no additional risk factors for complicated UTI: The usual duration is 7 days for a case of cystitis and up to a maximum of 14 days in the case of acute pyelonephritis.

6. Follow-up urine cultures are performed within 1 to 2 weeks of treatment discontinuation.

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