eMedicine Specialties > Emergency Medicine > Genitourinary

Urinary Tract Infection, Female: Follow-up

Author: David S Howes, MD, Residency Program Director, Professor of Medicine, Section of Emergency Medicine, University of Chicago/Pritzker School of Medicine
Contributor Information and Disclosures

Updated: Nov 20, 2009

Follow-up

Further Inpatient Care

  • The necessity for admission is based on host factors, age, risk of complicated infection, and likelihood of morbidity associated with failed outpatient treatment.
  • Admit all patients with complicated UTI. Complicating factors include the following:
    • Structural abnormalities (eg, calculi, tract anomalies, indwelling catheter, obstruction)
    • Metabolic disease (eg, diabetes, renal insufficiency)
    • Impaired host defenses (eg, HIV, current chemotherapy, underlying active cancer)
  • The following patients with clinically apparent uncomplicated pyelonephritis also should be admitted:
    • Those patients who are unable to maintain adequate oral hydration or have evidence of vasomotor instability or unrelenting fever despite antipyretic therapy
    • Those with debilitating pain or dehydration that cannot be corrected promptly in the ED
    • Patients with inadequate home care or resources to fill prescriptions or comply with the medical regimen (eg, homeless patients, adolescents, elderly patients in an acute illness setting who are at risk for clouded judgment, patients with substance abuse issues or other issues that will prevent adequate compliance)

Further Outpatient Care

  • The vast majority of patients with simple uncomplicated UTI may receive care as outpatients.

Transfer

  • Transfer is rarely an issue for patients with UTI.
  • Exceptions would include patients with complicated pyelonephritis who may require operative intervention to relieve obstruction.

Deterrence/Prevention

  • Sexually active women may attempt voiding immediately after intercourse to lessen the risk of coitus-related introduction of bacteria into the bladder.
  • Some authors recommend large urinary flow volumes as a measure that will reduce the risk of UTI.

Complications

  • Complications of simple lower UTI in otherwise healthy individuals are rare, chiefly revolving around issues of resistant organisms or re-infection with the same organism. Relapse of symptoms after a brief 3-day course of antibiotics suggests the presence of clinically unsuspected upper UTI and requires 10- to 14-day therapy.
  • More serious complications of UTI include the following:
    • Acute papillary necrosis with potential ureteric obstruction
    • Overwhelming sepsis syndrome with septic shock due to loss of vasomotor tone, capillary leak, and impaired myocardial performance
    • Perinephric abscess

Prognosis

  • Unfortunately, the morbidity from upper UTI, especially in the elderly or those patients with complicated disease, is substantial.
  • Factors associated with an unfavorable prognosis include the following:
    • Old age
    • General debility
    • Renal calculi or obstruction
    • Recent hospitalization
    • Urinary tract instrumentation or antibiotic therapy
    • Diabetes mellitus
    • Chronic nephropathy
    • Sickle cell anemia
    • Underlying cancer
    • Intercurrent chemotherapy

Patient Education

  • Proper adherence to the outpatient medical regimen, drinking fluids to enhance diuresis, frequent voiding, and drinking fruit juices to acidify the urine are helpful in reducing recurrent infection.
  • Postintercourse voiding may be helpful in reducing recurrent infection.
  • For excellent patient education resources, visit eMedicine's Kidneys and Urinary System Center. Also, see eMedicine's patient education articles Urinary Tract Infections and Bladder Control Problems.

Miscellaneous

Medicolegal Pitfalls

  • Do not assume that a sexually active female with dysuria has UTI without first excluding the possibility of STD-related cervicitis, vaginitis, or pelvic inflammatory disease.
  • Pyuria and bacteriuria always are treated during pregnancy, regardless of whether symptoms are present.
  • In all cases of upper UTI and in pregnant patients, obtain a urine culture. It may provide the physician or the follow-up physician with valuable information as to why things are not working out as planned for the patient.
  • Short 3-day courses of antibiotics are appropriate for a patient who appears to have a simple uncomplicated UTI with very brief duration of symptoms. Otherwise, err on the side of longer courses of antibiotic treatment for outpatients (ie, 7-10 d).
  • Admission for older patients with pyelonephritis is a good thing. Also admit young women with pyelonephritis who do not have the means to take care of themselves.
  • The fluoroquinolones are well tolerated and quite effective. They are probably the outpatient antibiotic treatment of choice for pyelonephritis. A recent study of selected patients with pyelonephritis treated as outpatients demonstrated that 7 days of ciprofloxacin was more effective than 14 days of co-trimoxazole. Unfortunately, fluoroquinolones are quite expensive compared to co-trimoxazole.
  • Older patients who appear toxic are more likely to have an obstructive picture complicating their UTI. Obtain a structural study to rule out this possibility.
 


More on Urinary Tract Infection, Female

Overview: Urinary Tract Infection, Female
Differential Diagnoses & Workup: Urinary Tract Infection, Female
Treatment & Medication: Urinary Tract Infection, Female
Follow-up: Urinary Tract Infection, Female
References
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References

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Further Reading

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Keywords

urinary tract infection women, UTI women, UTI treatment, UTI diagnosis, UTI symptoms, hemorrhagic cystitis, urinary urgency, cystitis, pyelonephritis, bacteriuria, enteric coliform bacteria, Escherichia coli 

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Contributor Information and Disclosures

Author

David S Howes, MD, Residency Program Director, Professor of Medicine, Section of Emergency Medicine, University of Chicago/Pritzker School of Medicine
David S Howes, MD is a member of the following medical societies: American College of Emergency Physicians, American College of Physicians-American Society of Internal Medicine, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Joseph A Salomone III, MD, EMS Medical Director, Kansas City, Missouri; Associate Professor and Staff Physician, Truman Medical Centers/UMKC School of Medicine
Joseph A Salomone III, MD is a member of the following medical societies: American Academy of Emergency Medicine, National Association of EMS Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Richard H Sinert, DO, Associate Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center
Richard H Sinert, DO is a member of the following medical societies: American College of Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Pamela L Dyne, MD, Professor of Clinical Medicine/Emergency Medicine, David Geffen School of Medicine at UCLA; Attending Physician, Department of Emergency Medicine, Olive View-UCLA Medical Center
Pamela L Dyne, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
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