© The Canadian Journal of Urology™; 19(Supplement 1); October 2012
43
Diagnosis and management of simple and complicated urinary tract infections (UTIs)
The most important group for whom screening and
treatment of asymptomatic bacteriuria has been shown
to be beneficial is pregnant women.
5
It is recommended
that all pregnant women should provide a urine
specimen for culture to screen for asymptomatic
bacteriuria during their routine visit to a physician
for prenatal care in their first trimester. If significant
bacteria is detected, these women should receive
appropriate antibiotic therapy and then a follow up
urine specimen should be submitted for a urine culture
test to ensure that the organism has been eliminated.
Untreated, asymptomatic bacteriuria in pregnant
women has been associated with an increased risk of
pyelonephritis in the mother and an increased risk of
delivering babies who are small for their gestational
age.
9
Asecond group of patients whomay benefit from
screening and treatment for asymptomatic bacteriuria
are those undergoing selected manipulation of their
genitourinary tract systems.
10
Aurine specimen should
be submitted before and after the procedure to ensure
that no significant amount of bacteria is present in the
bladder.
Uncomplicated UTIs
Several studies have evaluated a variety of approaches
for diagnosing and managing women with suspected
TABLE 1.
Underlying factors associated with
complicated urinary tract infections
•
Anatomical or functional abnormality of the urinary
tract system
•
Renal insufficiency
•
Presence of foreign body
•
Transplantation
•
Comorbid illness
•
Antimicrobial-resistant organism(s)
•
Recent antibiotic use*
•
Elderly
•
Male
•
Recurrent urinary tract infection
•
Pregnancy
•
Recent urologic procedure or manipulation of the
genitourinary tract system
•
Symptoms > 14 days
•
Immunocompromised host
*
Within 3 months of the UTI, regardless of which antibiotic
the patient received and for what reason
Asymptomatic bacteruria
Asymptomatic bacteriuria refers to the presence of a
significant amount of bacteria in a urine specimen that
was collected from a patient with no symptoms, and
whichwas sent for a laboratory urine culture test.
5
Most
often, the reason the specimen was submitted for urine
culture is unclear. Asymptomatic bacteriuria is common,
and 3% to 8% of premenopausal women and 4% to 43%
of postmenopausal womenmay have this condition.
5
In
most cases, treatment is not indicated, since there is no
evidence that patients would derive any benefit from it.
5
Uncomplicated UTIs
Although the distinction between uncomplicated and
complicated UTIs is not always clear, this distinction
does aid inmaking clinical decisions regarding patient
treatment and management.
6
Uncomplicated UTIs
are generally defined as those occurring in otherwise
healthy premenopausal women who have kidneys
and urinary tract systems with normal function.
Uncomplicated UTIs include infections in both the
lower urinary tract (cystitis) as well as the upper
urinary tract (pyelonephritis).
7
Patient symptoms may
have an acute or recent onset andmay include urinary
frequency, pain/burning on urination, urgency, foul
smelling/cloudy urine, other features of dysuria, as
well as features suggestive of an upper urinary tract
infection (pyelonephritis) such as flank pain and fever.
Complicated UTIs
Several factors, as listed in Table 1, may make a UTI
complicated. Complicated UTIs usually develop in
patients with urinary tract systems that are structurally
or functionally abnormal due to intrinsic or extrinsic
factors.
Treatment strategies
Asymptomatic bacteruria
Among women with asymptomatic bacteruria,
those who are pregnant or who are undergoing
a genitourinary procedure may require further
investigations or treatment (as discussed later).
Otherwise, most women with asymptomatic
bacteriuria—including elderly women, or those
with underlying diabetes, indwelling urinary-tract
catheters, or spinal-cord injuries—do not require
further investigations or treatment.
5,8
These patients
should be reassured that no harm will come to them
from not treating the bacteriuria and that a routine
urine culture test is not warranted. Similarly, there is
also no data to support the screening and/or treatment
for asymptomatic bacteriuria in men.
5
