eMedicine Specialties > Infectious Diseases > Genitourinary Tract Infections

Urinary Tract Infection, Females

Author: 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
Coauthor(s): Jeffrey M Tessier, MD, Assistant Professor, Department of Medicine, Uniformed Services University of the Health Sciences; Mary F Bavaro, MD, Chief, Division of Infectious Disease, Navy Medical Center, San Diego
Contributor Information and Disclosures

Updated: Jun 12, 2008

Introduction

Background

This article addresses pyelonephritis and cystitis as they apply to women; pediatric infections are not covered. (For information on pediatric urinary tract infections [UTIs] and UTIs in males, see the articles Urinary Tract Infection in eMedicine’s Pediatrics: General Medicine volume and Urinary Tract Infection, Males in eMedicine’s Infectious Diseases volume, respectively.) Nosocomial UTIs and their main risk factor, indwelling urethral catheters, are discussed, as well as infections in special hosts (patients with spinal injury, diabetes, transplants) and special conditions (candiduria, perirenal abscess).

For issues relating to multidrug-resistant organisms (eg, Acinetobacter) or particular organisms (gonorrhea, schistosomiasis), the reader should consult those particular articles. This article does not discuss urethritis, sexually transmitted diseases (STDs), or pelvic inflammatory disease (PID) in any detail.

UTIs may be referred to as cystitis or pyelonephritis, terms that refer to the lower and upper urinary tract, respectively. The terms bacteriuria and candiduria describe bacteria or yeast in the urine. Very ill patients may be referred to as having urosepsis.

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) of a bacterial species in a patient lacking symptoms of a UTI.

Uropathogens are specific bacteria that have been clinically associated with invasion of the urinary tract.

Complicated UTIs are defined as UTIs that are associated with metabolic disorders, that occur at sites other than the urinary bladder, or that are secondary to anatomic or functional abnormalities that impair urinary tract drainage. Most complicated UTIs are nosocomial in origin. The most common pathogens include Escherichia coli, enterococci, Pseudomonas aeruginosa, candidal species, and Klebsiella pneumoniae. Complicated UTIs may be subdivided into the following 4 categories:

  1. Structural abnormalities - Calculi, infected cysts, renal/bladder abscesses, certain forms of pyelonephritis, spinal cord injury (SCI), catheters
  2. Metabolic/hormonal abnormalities - Diabetes, pregnancy
  3. Impaired host responses - Transplant recipients, patients with AIDS
  4. Unusual pathogens - Yeast, etc

Pathophysiology

In general, 3 main mechanisms are responsible for UTIs, including (1) colonization with ascending spread, (2) hematogenous spread, and (3) periurogenital spread of infection. Specific organism characteristics, defects in host defenses, and pathophysiologic details concerning particular UTIs are discussed below.

Bacterial virulence

Uropathogenic bacteria, derived from a subset of fecal flora, have traits that enable adherence, growth, and resistance of host defenses, resulting in 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). 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 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 to 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 of 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.

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.

Pathophysiologic details of complicated urinary tract infections

Pyelonephritis is almost always the result of bacteria migrating from the bladder to the renal parenchyma, which is enhanced by vesicourethral reflux. In uncomplicated pyelonephritis, the bacterial invasion and renal damage are limited to the pyelocalyceal-medullary region; in complicated pyelonephritis, all regions of the kidney may be affected. If the infection progresses, bacteria may invade the bloodstream, resulting in bacteremia.

Complicated pyelonephritis results from structural and functional abnormalities, urologic manipulations, or underlying disease. Complicated pyelonephritis includes pyelonephritis in men and pyelonephritis elderly people. Patients with diabetes may develop emphysematous or xanthogranulomatous pyelonephritis and necrotizing papillitis.

Subclinical pyelonephritis should be considered in indigent people; pregnant women; people with diabetes; people with alcoholism; and patients with a history of pyelonephritis, renal transplant, UTI before age 12 years, and more than 3 UTIs in the past year.

Calculi related to UTIs most commonly occur in women with recurrent UTIs from Proteus, Pseudomonas, and Providencia species (see Image 1); bacterial biofilms serve to assist struvite growth. Because magnesium ammonium phosphate is acid soluble, stone formation does not tend to occur with a urinary pH lower than 7.19. Increases in ammonia raise the pH and injure the uroepithelial glycosaminoglycan layer, contributing to bacterial adherence. Alkalinity also increases the amount of phosphate and carbonate available to bind calcium and magnesium.

Renal corticomedullary abscesses usually are associated with vesicoureteral reflux or urinary tract obstruction, and the usual organisms include E coli, Klebsiella species, and Proteus species. Clinical syndromes include acute focal bacterial nephritis, acute multifocal bacterial nephritis, emphysematous pyelonephritis, and xanthogranulomatous pyelonephritis.

Acute focal bacterial nephritis is also known as acute lobar nephronia or focal pyelonephritis. This is an acute bacterial interstitial nephritis affecting a single renal lobe. Acute multifocal bacterial nephritis affects more than 1 lobe (see Image 2). Emphysematous pyelonephritis is a severe, necrotizing form of acute multifocal bacterial nephritis. Retroperitoneal (ie, extraluminal) gas may be observed in the renal parenchyma and perirenal space on radiographs. This is observed most commonly in people with diabetes, but it also may be observed in patients with immunocompromise or obstruction.

Xanthogranulomatous pyelonephritis is a severe chronic infection of the renal parenchyma. The kidney is enlarged and is fixed to the retroperitoneum by either perirenal fibrosis or an extension of the granulomatous process. The inciting event appears to be renal obstruction and chronic UTI. Predisposing factors include renal calculi, lymphatic obstruction, renal ischemia, dyslipidemia, diabetes, and primary hyperparathyroidism.

A perinephric abscess is defined as a collection of purulent material between the renal capsule and Gerota fascia. A perinephric abscess may develop secondary to an intrarenal abscess, a renal cortical abscess, xanthogranulomatous pyelonephritis, chronic or recurrent pyelonephritis, or from hematogenous dissemination. Predisposing factors are similar to those for intrarenal abscess. Approximately 25% of patients have diabetes.

Over time, patients with diabetes may develop cystopathy, nephropathy, and renal papillary necrosis, complications that predispose them to UTIs. Long-term effects of diabetic cystopathy include vesicourethral reflux and recurrent UTIs; as many as 30% of women with diabetes have some degree of cystocele, cystourethrocele, or rectocele.

Vaginal candidiasis and vascular disease also play a role in recurrent infections. Hyperglycemia causes neutrophil dysfunction by increasing intracellular calcium levels, interfering with actin and, thus, diapedesis and phagocytosis.

Renal cortical abscesses (ie, renal carbuncles) usually result from hematogenous spread of bacteria. Primary sources of infection include skin infections, osteomyelitis, and endovascular infections. These are observed commonly in users of injection drug, people with diabetes, and patients on dialysis. The most common organism isolated is Staphylococcus aureus. Ten percent of cortical abscesses may rupture through the renal capsule and form a perinephric abscess.

Autosomal dominant polycystic kidney disease can lead to end-stage renal disease. Cysts may become infected from either bacteremia or from bacteriuria.

Several factors increase the risk of UTI in pregnancy. These factors include relative obstruction of the ureters (secondary to the enlarging uterus), smooth muscle relaxation of the ureter and bladder (secondary to progesterone), and aminoaciduria and glycosuria, which provide a favorable environment for bacteria to grow. E coli is the most common organism isolated from cultures, although P mirabilis and K pneumoniae also are observed. Less common agents include group B streptococci and Staphylococcus saprophyticus. Group B streptococci are isolated in approximately 5% of infections and have been linked to preterm labor; these patients should receive prophylactic antibiotics during delivery to reduce the risk of neonatal sepsis.

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. The presence of Candida species in the urine usually represents colonization and not infection, and, as such, not all patients with candiduria require treatment. A lower threshold for initiating treatment exists for patients with diabetes, history of renal transplantation, or genitourinary abnormalities.

Frequency

United States

UTIs in women are very common; approximately 25-40% of women in the United States aged 20-40 years have had a UTI. In 1998, approximately 3.2% of emergency department visits were related to symptoms involving the genitourinary tract. Estimates based on office and emergency department visits suggest per annum about 7 million episodes of acute cystitis and 250,000 episodes of acute pyelonephritis. Ten to 15% of nephrolithiasis episodes are secondary to organisms associated with stone production. The incidence of renal and perirenal abscesses is 1-10 cases per 10,000 population. Some estimate that UTIs cost at least 1 billion dollars per year.

Patients with spinal cord injuries are at an increased risk for UTIs; lower rates occur in those with incomplete injuries. In patients practicing clean intermittent catheterization, the mean incidence of UTIs is 10.3 per1000 catheter days; after 3 months, the rate is fewer than 2 per 1000 catheter days. Once a urethral catheter is in place, the daily incidence of bacteriuria is 3-10%. Because most become bacteriuric by 30 days, that is a convenient dividing line between short- and long-term catheterization.

International

UTIs have been well studied in Sweden and other parts of Europe, and these data are referred to frequently in this article.

Data from the tropics are 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.

Tuberculosis (TB) of the kidney results from hematogenous spread but is relatively rare in developing countries. Unlike most other extrapulmonary manifestations of the disease, TB of the kidney does not become manifest until 5-15 years after the primary infection. Constitutional symptoms are uncommon, and most patients present with symptoms of bladder irritation. Initially, pyuria is observed, and, with progression of the disease, proteinuria and blood may be observed as well. Repeated urine samples should be sent for mycobacterial culture. A loss of calyceal architecture and ureteric obstruction may be observed on imaging studies. Concurrent pulmonary disease is present in 5% of patients, and the tuberculin test rarely is helpful. Antituberculous medicines should be administered for 6 months. If the ureter is obstructed, corticosteroids have been advocated; if obstruction persists, surgical intervention is necessary.

Mortality/Morbidity

  • The mortality associated with acute uncomplicated cystitis among women aged 20-60 years appears to be negligible. A longitudinal cohort study of Swedish women showed a higher mortality among women with a history of UTI compared with age-matched women without this history (37% versus 28% in 10 y, P <0.001).1 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.
  • Groups at risk for UTIs associated with calculi include those with dysfunctional voiding, urinary intestinal diversion, indwelling urinary catheters, and vesicoureteral reflux.

Race

No racial predilection exists.

Sex

Uncomplicated UTIs are much more common among 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.

  • Renal carbuncles are more common in men than women by a ratio of 3:1 and are most common in the second to fourth decades of life. The right kidney is involved most commonly (63%).
  • Renal corticomedullary abscesses affect men and women equally; xanthogranulomatous pyelonephritis affects more women than men.

Age

The incidence of UTI in women tends to increase with increasing age. Several peaks above baseline correspond with specific events, including an increase among women aged 18-30 years (associated with honeymoon cystitis and pregnancy). Older adults have is a higher incidence of renal corticomedullary abscesses. This article does not discuss UTIs in children.

Clinical

History

  • Acute urethritis
    • This topic is addressed in greater detail in Urethritis. The symptoms of acute urethritis overlap with those of cystitis, including acute dysuria and urinary hesitancy.
    • Urethral discharge is much more suggestive of urethritis, while bladder-related symptoms, such as urgency, polyuria, and incomplete voids, are more consistent with cystitis.
    • Fever may be a component of urethritis-related syndromes (eg, Reiter syndrome, Behçet syndrome) but rarely is observed in acute cystitis.
  • Acute cystitis
    • The symptoms of dysuria, urgency, hesitancy, polyuria, and incomplete voids also may be accompanied by urinary incontinence, gross hematuria, and suprapubic or low back pain.
    • The predominant complaints relate to the inflamed bladder mucosa. Constitutional symptoms, such as fever, nausea, and anorexia, are rare or mild.
  • Acute pyelonephritis
    • Unlike urethritis and cystitis, pyelonephritis may present with a paucity of lower urinary tract symptoms.
    • The classic triad of fever, costovertebral angle pain, and nausea and/or vomiting may be present, though not necessarily occurring together temporally.
    • Hematuria may occur but is more suggestive of nephrolithiasis in the presence of localizing back or flank pain.
    • Fever and vomiting may suggest gastroenteritis. Patients also may present with right upper quadrant pain radiating to the back, mimicking cholecystitis or pancreatitis.
  • Complicated urinary tract infections
    • UTIs associated with calculi may be insidious or asymptomatic. Patients may present with recurrent UTIs, abdominal pain, fever, gross hematuria, urinary fistulae, renal failure, or urosepsis.
    • Patients with renal corticomedullary abscesses present with chills, fever, and flank or abdominal pain. Patients may have dysuria and/or nausea/vomiting. Leukocytosis may be present. Bacteriuria, pyuria, hematuria, or proteinuria may be present as the intrarenal abscesses drain in the collecting system, but the urinalysis results may be normal in as many as 30% of patients. Bacteremia may be observed in acute focal or multifocal bacterial nephritis.
    • Patients with perinephric abscesses most commonly present with chills, fever, flank or abdominal pain, and dysuria. The physical examination is notable for flank and costovertebral angle tenderness and possibly a palpable mass.
    • Renal cortical abscess patients may present with chills, fever, and flank or abdominal pain. Patients may present with a flank mass or a bulge in the lumbar region. Some have abnormal results on lung examination of the affected side (dullness to percussion, rales). Blood and urine culture results usually are negative, but the white blood cell (WBC) count is often elevated.
    • In patients with SCI, signs and symptoms suggestive of a UTI are malodorous and cloudy urine, muscular spasticity, fatigue, fevers, chills, and autonomic instability. Patients with lesions above T6 may exhibit autonomic dysreflexia to noxious stimuli (such as an overdistended bladder). The sympathetic response below the level of injury is uninhibited, producing severe vasoconstriction and reflexive bradycardia. If the patient is febrile, this may appear as a pulse-temperature dissociation.

Physical

  • Acute cystitis  
    • Abnormal physical examination findings generally are lacking in women with acute cystitis. Patients may demonstrate some suprapubic tenderness to palpation.
    • The pelvic examination reveals no abnormalities unless another process, such as vaginitis, is mimicking or occurring simultaneously with cystitis.
  • Acute pyelonephritis  
    • Fever in a young woman with symptoms referable to the urinary tract supports a diagnosis of pyelonephritis. Unilateral or bilateral costovertebral angle tenderness may be present.
    • A pelvic examination may reveal findings suggestive of PID, such as cervical motion tenderness or vaginal discharge.
    • The abdominal examination may reveal upper quadrant tenderness, but peritoneal symptoms should not be present in acute uncomplicated pyelonephritis.
  • Patients with perinephric abscesses most commonly present with fever, chills, and flank tenderness; they may have a palpable mass.

Causes

E coli causes 70-95% of both upper and lower UTIs. The remainder of infections is composed of various organisms, including S saprophyticus, Proteus species, Klebsiella species, Enterococcus faecalis, other Enterobacteriaceae, and yeast. Some species are more common in certain subgroups, such as S saprophyticus in young women.

  • Sexual intercourse contributes to increased risk, as does use of a diaphragm and/or spermicide. Women who are elderly, pregnant, or have preexisting urinary tract structural abnormalities or obstruction carry a higher risk of UTI.
  • Most complicated UTIs are nosocomial in origin. The most common pathogens include E coli, enterococci, P aeruginosa, Candida species, and K pneumoniae.
  • Calculi related to UTIs most commonly occur in women who experience recurrent UTIs with Proteus, Pseudomonas, and Providencia species.
  • Perinephric abscesses are associated most commonly 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 1,000 CFU 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.
  • Patients with SCI develop UTIs with microorganisms that form dense biofilms on the bladder wall; thus, these infections are difficult to eradicate. Organisms that commonly cause infections include Proteus, Pseudomonas, Klebsiella, Serratia, and Providencia species, along with enterococci and staphylococci. Approximately 70% of infections are polymicrobial.

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References
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References

  1. Molander U, Arvidsson L, Milsom I, Sandberg T. A longitudinal cohort study of elderly women with urinary tract infections. Maturitas. Feb 15 2000;34(2):127-31. [Medline].

  2. Abdul-Halim H, Kehinde EO, Abdeen S, Lashin I, Al-Hunayan AA, Al-Awadi KA. Severe emphysematous pyelonephritis in diabetic patients: diagnosis and aspects of surgical management. Urol Int. 2005;75(2):123-8. [Medline].

  3. Azzarone G, Liewehr S, O'Connor K. Cystitis. Pediatr Rev. Dec 2007;28(12):474-6. [Medline].

  4. Barzaga R, Cunha BA. Infections in the elderly (Part 1): Urinary tract infections. Infect Dis Pract. 1991;15:1-7.

  5. Behr MA, Drummond R, Libman MD, Delaney JS, Dylewski JS. Fever duration in hospitalized acute pyelonephritis patients. Am J Med. Sep 1996;101(3):277-80. [Medline].

  6. Belas R. Proteus mirabilis swarmer cell differentiation and urinary tract infection. In: Mobley HL, Warren JW, eds. Urinary Tract Infections. Washington, DC: ASM Press; 1996:271-98.

  7. Berger RE. Risk factors associated with acute pyelonephritis in healthy women. J Urol. Nov 2005;174(5):1841. [Medline].

  8. Bergeron MG. Treatment of pyelonephritis in adults. Med Clin North Am. May 1995;79(3):619-49. [Medline].

  9. Brown PD. Antimicrobial Selection in the Treatment of Pyelonephritis. Curr Infect Dis Rep. Dec 2004;6(6):457-461. [Medline].

  10. Chen Y, Nitzan O, Saliba W, Chazan B, Colodner R, Raz R. Are blood cultures necessary in the management of women with complicated pyelonephritis?. J Infect. Oct 2006;53(4):235-40. [Medline].

  11. Choi YD, Yang WJ, Do SH, Kim DS, Lee HY, Kim JH. Vesicoureteral reflux in adult women with uncomplicated acute pyelonephritis. Urology. Jul 2005;66(1):55-8. [Medline].

  12. Chua A, Klein NC, Cunha BA. The Diagnostic Significance of Urinary Nitrate in Hospitalized Patients with Catheter Associated Bacteruria. Infectious Disease Practice. 1999;23:9-11.

  13. Connolly A, Thorp JM Jr. Urinary tract infections in pregnancy. Urol Clin North Am. Nov 1999;26(4):779-87. [Medline].

  14. Cox AR, Kuan JK, Razvi H. Emphysematous pyelonephritis: a case report and review of the literature. Can J Urol. Apr 2006;13(2):3039-43. [Medline].

  15. Cunha BA. Antibiotic Concentration Dependent Susceptibility of Urinary Tract. Antibiotics for Clinicians. 1999;3:57-8.

  16. Cunha BA. Antibiotic Essentials. 7th ed. Royal Oak, Mich: Physicians Press; 2008.

  17. Cunha BA. Clinical concepts in the treatment of urinary tract infections. Antibiot Clin. 1999;3:88-93.

  18. Cunha BA. Clinical Concepts in the Treatment of Urinary Tract Infections. Antibiotics for Clinicians. 1999;3:88-93.

  19. Cunha BA. Urosepsis. In: Infectious Diseases in Critical Care Medicine. New York, NY: Marcel Dekker Inc; 1998.

  20. Cunha BA. Nitrofurantoin: A Review. Advances in Therapy. 1989;6:213-36.

  21. Cunha BA. Nosocomial catheter-associated urinary tract infections. Hosp Phys. 1986;22:13-16.

  22. Cunha BA. Single dose therapy of urinary tract infections. Hosp Phys. 1983;19:35-37.

  23. Cunha BA. Staphylococcus saprophyticus urinary tract infections. Intern Med. 1985;6:82-89.

  24. Cunha BA. The fluoroquinolones for urinary tract infections: a review. Adv Ther. Nov-Dec 1994;11(6):277-96. [Medline].

  25. Cunha BA. Urinary tract infections. 1. Pathophysiology and diagnostic approach. Postgrad Med. Dec 1981;70(6):141-5. [Medline].

  26. Cunha BA. Urine gram stain in urosepsis. Intern Med. 1997;18:75-78.

  27. Cunha BA. Urosepsis. J Crit Illn. 1997;12:616-625.

  28. Cunha BA. Urosepsis - Diagnostic and therapeutic approach. Intern Med. 1996;17:85-93.

  29. Cunha BA, Comer JB. Pharmacokinetic considerations in the treatment of urinary tract infections. Conn Med. Jun 1979;43(6):347-53. [Medline].

  30. Dalla Palma L, Pozzi-Mucelli F, Ene V. Medical treatment of renal and perirenal abscesses: CT evaluation. Clin Radiol. Dec 1999;54(12):792-7. [Medline].

  31. Delzell JE Jr, Lefevre ML. Urinary tract infections during pregnancy. Am Fam Physician. Feb 1 2000;61(3):713-21. [Medline].

  32. Dembry LM, Andriole VT. Renal and perirenal abscesses. Infect Dis Clin North Am. Sep 1997;11(3):663-80. [Medline].

  33. Donnenberg MS, Welch RA. Virulence determinants of uropathogenic Escherichia coli. In: Mobley HL, Warren JW, eds. Urinary Tract Infections. Washington, DC: ASM Press; 1996:135-74.

  34. Eknoyan G, Qunibi WY, Grissom RT, Tuma SN, Ayus JC. Renal papillary necrosis: an update. Medicine (Baltimore). Mar 1982;61(2):55-73. [Medline].

  35. Engel JD, Schaeffer AJ. Evaluation of and antimicrobial therapy for recurrent urinary tract infections in women. Urol Clin North Am. Nov 1998;25(4):685-701, x. [Medline].

  36. Falk L, Fredlund H, Jensen JS. Signs and symptoms of urethritis and cervicitis among women with or without Mycoplasma genitalium or Chlamydia trachomatis infection. Sex Transm Infect. Feb 2005;81(1):73-8. [Medline].

  37. Ferry SA, Holm SE, Stenlund H, Lundholm R, Monsen TJ. The natural course of uncomplicated lower urinary tract infection in women illustrated by a randomized placebo controlled study. Scand J Infect Dis. 2004;36(4):296-301. [Medline].

  38. Fioriti D, Penta M, Mischitelli M, Degener AM, Pierangeli A, Gentile V, et al. Interstitial cystitis and infectious agents. Int J Immunopathol Pharmacol. Oct-Dec 2005;18(4):799-804. [Medline].

  39. Fisk DT, Saint S, Tierney LM Jr. Clinical problem-solving. Back to the basics. N Engl J Med. Sep 2 1999;341(10):747-50. [Medline].

  40. Foxman B, Frerichs RR. Epidemiology of urinary tract infection: I. Diaphragm use and sexual intercourse. Am J Public Health. Nov 1985;75(11):1308-13. [Medline].

  41. Gupta K, Hooton TM, Roberts PL, Stamm WE. Patient-initiated treatment of uncomplicated recurrent urinary tract infections in young women. Ann Intern Med. Jul 3 2001;135(1):9-16. [Medline].

  42. Gupta K, Hooton TM, Stamm WE. Increasing antimicrobial resistance and the management of uncomplicated community-acquired urinary tract infections. Ann Intern Med. Jul 3 2001;135(1):41-50. [Medline].

  43. Hill JB, Sheffield JS, McIntire DD, Wendel GD Jr. Acute pyelonephritis in pregnancy. Obstet Gynecol. Jan 2005;105(1):18-23. [Medline].

  44. Hooton TM, Scholes D, Hughes JP, Winter C, Roberts PL, Stapleton AE, et al. A prospective study of risk factors for symptomatic urinary tract infection in young women. N Engl J Med. Aug 15 1996;335(7):468-74. [Medline].

  45. Hooton TM, Stamm WE. Diagnosis and treatment of uncomplicated urinary tract infection. Infect Dis Clin North Am. Sep 1997;11(3):551-81. [Medline].

  46. Huang JJ, Sung JM, Chen KW, Ruaan MK, Shu GH, Chuang YC. Acute bacterial nephritis: a clinicoradiologic correlation based on computed tomography. Am J Med. Sep 1992;93(3):289-98. [Medline].

  47. Huang JJ, Tseng CC. Emphysematous pyelonephritis: clinicoradiological classification, management, prognosis, and pathogenesis. Arch Intern Med. Mar 27 2000;160(6):797-805. [Medline].

  48. Jacobs L, Dorsainvil P, Cunha BA. Urinary Tract Infections in Patients with IgA and IgG Multiple Myeloma. Infectious Disease Practice. 2006;30:483-6.

  49. Jensen JS. Mycoplasma genitalium: the aetiological agent of urethritis and other sexually transmitted diseases. J Eur Acad Dermatol Venereol. Jan 2004;18(1):1-11. [Medline].

  50. Johnson JR, Owens K, Gajewski A, Kuskowski MA. Bacterial characteristics in relation to clinical source of Escherichia coli isolates from women with acute cystitis or pyelonephritis and uninfected women. J Clin Microbiol. Dec 2005;43(12):6064-72. [Medline].

  51. Kahan NR, Chinitz DP, Kahan E. Longer than recommended empiric antibiotic treatment of urinary tract infection in women: an avoidable waste of money. J Clin Pharm Ther. Feb 2004;29(1):59-63. [Medline].

  52. Kang D, Klein NC, Cunha BA. Nosocomial enterococcal urosepsis in a compromised host. Heart Lung. Sep 1991;20(5 Pt 1):515-6. [Medline].

  53. Klausner HA, Brown P, Peterson J, Kaul S, Khashab M, Fisher AC, et al. A trial of levofloxacin 750 mg once daily for 5 days versus ciprofloxacin 400 mg and/or 500 mg twice daily for 10 days in the treatment of acute pyelonephritis. Curr Med Res Opin. Nov 2007;23(11):2637-45. [Medline].

  54. Kontiokari T, Sundqvist K, Nuutinen M, Pokka T, Koskela M, Uhari M. Randomised trial of cranberry-lingonberry juice and Lactobacillus GG drink for the prevention of urinary tract infections in women. BMJ. Jun 30 2001;322(7302):1571. [Medline].

  55. Kudalkar D, Reme P, Cunha BA. Xanthogranulomatous pyelonephritis complicated by psoas abscess. Heart Lung. Sep-Oct 2004;33(5):339-42. [Medline].

  56. Latuszynski DK, Schoch P, Qadir MT, Cunha BA. Proteus penneri urosepsis in a patient with diabetes mellitus. Heart Lung. Mar-Apr 1998;27(2):146-8. [Medline].

  57. Lifshitz E, Kramer L. Outpatient urine culture: does collection technique matter?. Arch Intern Med. Sep 11 2000;160(16):2537-40. [Medline].

  58. Lightner DJ. Contemporary urologic management of patients with spinal cord injury. Mayo Clin Proc. May 1998;73(5):434-8. [Medline].

  59. McCarty JM, Richard G, Huck W, Tucker RM, Tosiello RL, Shan M, et al. A randomized trial of short-course ciprofloxacin, ofloxacin, or trimethoprim/sulfamethoxazole for the treatment of acute urinary tract infection in women. Ciprofloxacin Urinary Tract Infection Group. Am J Med. Mar 1999;106(3):292-9. [Medline].

  60. Mori T, Aisa Y, Shimizu T, Ikeda Y, Okamoto S, Okada K, et al. Hemorrhagic cystitis caused by adenovirus type 34 after allogeneic bone marrow transplantation. Transplantation. Mar 15 2005;79(5):624. [Medline].

  61. Myers JM, Gill MV, Cunha BA. Corynebacterium urealyticum urinary tract infections. Antimicrobs Infect Dis Newsletter. 1996;14:83-84.

  62. O'Leary JJ, Domenico P, Cunha BA. Importance of Urinalysis in Infectious Disease. Hospital Physician. 1991;27:25-30.

  63. Papanicolaou N, Pfister RC. Acute renal infections. Radiol Clin North Am. Sep 1996;34(5):965-95. [Medline].

  64. Paradisi F, Corti G, Mangani V. Urosepsis in the critical care unit. Crit Care Clin. Apr 1998;14(2):165-80. [Medline].

  65. Patterson JE, Andriole VT. Bacterial urinary tract infections in diabetes. Infect Dis Clin North Am. Sep 1997;11(3):735-50. [Medline].

  66. Perkash I. Long-term urologic management of the patient with spinal cord injury. Urol Clin North Am. Aug 1993;20(3):423-34. [Medline].

  67. Peterson JR, Roth EJ. Fever, bacteriuria, and pyuria in spinal cord injured patients with indwelling urethral catheters. Arch Phys Med Rehabil. Nov 1989;70(12):839-41. [Medline].

  68. Pinson AG, Philbrick JT, Lindbeck GH, Schorling JB. ED management of acute pyelonephritis in women: a cohort study. Am J Emerg Med. May 1994;12(3):271-8. [Medline].

  69. Pugliese A, Klein NC, Cunha BA. Parasitic and fungal urinary tract infections. Infect Med. 1992;4:10-16.

  70. Quintiliani R, Klimek JJ, Cunha BA, Maderazo EG. Bacteremia After Manipulation of the Urinary Tract: The Importance of Pre-existing Urinary Tract Disease and Compromised Host Defenses. Postgraduate Medical Journal. 1978;54:668-671.

  71. Raffi HS, Bates JM Jr, Laszik Z, Kumar S. Tamm-Horsfall protein acts as a general host-defense factor against bacterial cystitis. Am J Nephrol. Nov-Dec 2005;25(6):570-8. [Medline].

  72. Raz R, Rottensterich E, Leshem Y, Tabenkin H. Double-blind study comparing 3-day regimens of cefixime and ofloxacin in treatment of uncomplicated urinary tract infections in women. Antimicrob Agents Chemother. May 1994;38(5):1176-7. [Medline].

  73. Raz R, Stamm WE. A controlled trial of intravaginal estriol in postmenopausal women with recurrent urinary tract infections. N Engl J Med. Sep 9 1993;329(11):753-6. [Medline].

  74. Reid G, Nicolle LE. Asymptomatic bacteriuria in spinal cord patients and the elderly. Urol Clin North Am. Nov 1999;26(4):789-95. [Medline].

  75. Remer EE, Peacock WFIV. Pyocystis: two case reports of patients in renal failure. J Emerg Med. Aug 2000;19(2):131-3. [Medline].

  76. Roberts JA. Management of pyelonephritis and upper urinary tract infections. Urol Clin North Am. Nov 1999;26(4):753-63. [Medline].

  77. Ronald AR, Harding GK. Complicated urinary tract infections. Infect Dis Clin North Am. Sep 1997;11(3):583-92. [Medline].

  78. Saint S, Elmore JG, Sullivan SD, Emerson SS, Koepsell TD. The efficacy of silver alloy-coated urinary catheters in preventing urinary tract infection: a meta-analysis. Am J Med. Sep 1998;105(3):236-41. [Medline].

  79. Saint S, Lipsky BA. Preventing catheter-related bacteriuria: should we? Can we? How?. Arch Intern Med. Apr 26 1999;159(8):800-8. [Medline].

  80. Savaris RF, Teixeira LM, Torres TG. Bladder tenderness as a physical sign for diagnosing cystitis in women. Int J Gynaecol Obstet. Jun 2006;93(3):256-7. [Medline].

  81. Schaeffer AJ. Renal imaging in pyelonephritis. J Urol. Mar 2005;173(3):845-6. [Medline].

  82. Schwartz BF, Stoller ML. Nonsurgical management of infection-related renal calculi. Urol Clin North Am. Nov 1999;26(4):765-78, viii. [Medline].

  83. Sedor J, Mulholland SG. Hospital-acquired urinary tract infections associated with the indwelling catheter. Urol Clin North Am. Nov 1999;26(4):821-8. [Medline].

  84. Shah HN, Jain P, Chibber PJ. Renal tuberculosis simulating xanthogranulomatous pyelonephritis with contagious hepatic involvement. Int J Urol. Jan 2006;13(1):67-8. [Medline].

  85. Sharifi R, Geckler R, Childs S. Treatment of urinary tract infections: selecting an appropriate broad-spectrum antibiotic for nosocomial infections. Am J Med. Jun 24 1996;100(6A):76S-82S. [Medline].

  86. Sheffield JS, Cunningham FG. Urinary tract infection in women. Obstet Gynecol. Nov 2005;106(5 Pt 1):1085-92. [Medline].

  87. Sobel JD. Pathogenesis of urinary tract infection. Role of host defenses. Infect Dis Clin North Am. Sep 1997;11(3):531-49. [Medline].

  88. Stamatiou C, Petrakos G, Bovis C, Panagopoulos P, Economou A, Karkanis C. Efficacy of prophylaxis in women with sex induced cystitis. Clin Exp Obstet Gynecol. 2005;32(3):193-5. [Medline].

  89. Stamm WE. Measurement of pyuria and its relation to bacteriuria. Am J Med. Jul 28 1983;75(1B):53-8. [Medline].

  90. Stamm WE, Hooton TM. Management of urinary tract infections in adults. N Engl J Med. Oct 28 1993;329(18):1328-34. [Medline].

  91. Stanford EJ, Mattox TF, Parsons JK, McMurphy C. Prevalence of benign microscopic hematuria among women with interstitial cystitis: implications for evaluation of genitourinary malignancy. Urology. May 2006;67(5):946-9. [Medline].

  92. Stapleton A. Prevention of recurrent urinary-tract infections in women. Lancet. Jan 2 1999;353(9146):7-8. [Medline].

  93. Stapleton A, Stamm WE. Prevention of urinary tract infection. Infect Dis Clin North Am. Sep 1997;11(3):719-33. [Medline].

  94. Steinke DT, Seaton RA, Phillips G, MacDonald TM, Davey PG. Factors associated with trimethoprim-resistant bacteria isolated from urine samples. J Antimicrob Chemother. Jun 1999;43(6):841-3. [Medline].

  95. Stone SC, Mallon WK, Childs JM, Docherty SD. Emphysematous pyelonephritis: clues to rapid diagnosis in the Emergency Department. J Emerg Med. Apr 2005;28(3):315-9. [Medline].

  96. Svanborg C, Godaly G. Bacterial virulence in urinary tract infection. Infect Dis Clin North Am. Sep 1997;11(3):513-29. [Medline].

  97. Takai K, Aoki A, Suga A, Tollemar J, Wilczek HE, Naito K, et al. Urinary tract infections following renal transplantation. Transplant Proc. Nov 1998;30(7):3140-1. [Medline].

  98. Teglia MQ, Teglia OF, Cunha BA. Staphylococcus saprophyticus urinary tract infections. Emerg Med. 1991;23:121-122.

  99. Tolkoff-Rubin NE, Rubin RH. Urinary tract infection in the immunocompromised host. Lessons from kidney transplantation and the AIDS epidemic. Infect Dis Clin North Am. Sep 1997;11(3):707-17. [Medline].

  100. Van Nostrand JD, Junkins AD, Bartholdi RK. Poor predictive ability of urinalysis and microscopic examination to detect urinary tract infection. Am J Clin Pathol. May 2000;113(5):709-13. [Medline].

  101. Vorland LH, Carlson K, Aalen O. An epidemiological survey of urinary tract infections among outpatients in Northern Norway. Scand J Infect Dis. 1985;17(3):277-83. [Medline].

  102. Waites KB, Chen Y, DeVivo MJ, Canupp KC, Moser SA. Antimicrobial resistance in gram-negative bacteria isolated from the urinary tract in community-residing persons with spinal cord injury. Arch Phys Med Rehabil. Jun 2000;81(6):764-9. [Medline].

  103. Warren J. Clinical presentations and epidemiology of urinary tract infections. In: Mobley HL, Warren JW, eds. Urinary Tract Infections. Washington, DC: ASM Press; 1996:3-27.

  104. Warren JW. Catheter-associated urinary tract infections. Infect Dis Clin North Am. Sep 1997;11(3):609-22. [Medline].

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Further Reading

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Keywords

urinary tract infection, UTI, urinary infection, cystitis, pyelonephritis, bacteriuria, candiduria, urosepsis, sexually transmitted disease, STD, Escherichia coli, E coli, Pseudomonas aeruginosa, P aeruginosa, Klebsiella pneumoniae, K pneumoniae, candidal species, enterococcal species, enterococci, pelvic inflammatory disease, PID, yeast infection, uropathogens, hematuria, indwelling urethral catheter, indwelling urethral catheterization

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Contributor Information and Disclosures

Author

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, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Coauthor(s)

Jeffrey M Tessier, MD, Assistant Professor, Department of Medicine, Uniformed Services University of the Health Sciences
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.

Mary F Bavaro, MD, Chief, 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, American Medical Association, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Medical Editor

Klaus-Dieter Lessnau, MD, FCCP, Clinical Associate Professor of Medicine, New York University School of Medicine; Medical Director, Pulmonary Physiology Laboratory; Director of Research in Pulmonary Medicine, Department of Medicine, Section of Pulmonary Medicine, Lenox Hill Hospital
Klaus-Dieter Lessnau, MD, FCCP is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Medical Association, American Society for Artificial Internal Organs, American Thoracic Society, Physicians for Social Responsibility, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Mark Jeffrey Noble, MD, Consulting Staff, Urologic Institute, Cleveland Clinic Foundation
Mark Jeffrey Noble, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, American Urological Association, Kansas Medical Society, Sigma Xi, Society of University Urologists, and Southwestern Oncology Group
Disclosure: Nothing to disclose.

CME Editor

Eleftherios Mylonakis, MD, Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital
Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Chief Editor

Michael Stuart Bronze, MD, Professor, Stewart G Wolf Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center
Michael Stuart Bronze, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physician Executives, American College of Physicians, American College of Physicians-American Society of Internal Medicine, American Federation for Clinical Research, American Medical Association, American Society for Microbiology, Association of Professors of Medicine, Association of Program Directors in Internal Medicine, Infectious Diseases Society of America, Oklahoma State Medical Association, and Southern Society for Clinical Investigation
Disclosure: Nothing to disclose.

 
 
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