Treatment of Urinary Tract Infection (UTI)

Treatment of Single isolated attack of UTI

Pretreatment urine culture is sought-after but not obligatory. In primary care, a positive dipstick test for nitrite and leucocyte esterase is enough. Treatment is over 3-5 days with amoxicillin (250 mg three times daily), nitrofurantoin (50 mg three times daily), trimethoprim (200 mg twice daily) or an oral cephalosporin. The treatment regimen is customized according to the result of urine culture and sensitivity test report, and/or the clinical response. For resistant organisms the alternative drugs are co-amoxiclav, ciprofloxacin or, norfloxacillin.

A high at least 2 Liter daily fluid intake is advised during treatment and also for some consequent weeks. Urinalysis, microscopy and culture is repeated


5 days following treatment. 'Single shot' treatment with 3 g of amoxicillin or 1.92 g of co-trimoxazole can be prescribed for those with bladder symptoms of less than 36 hours' duration and those, who have no previous history of UTI.

If the patient is acutely sick with high degree of fever, loin pain and tenderness (acute pyelonephritis), a broad-spectrum antibiotic is prescribed intravenously, such as aztreonam, cefuroxime, ciprofloxacin or gentamicin switching to a further 7 days' with oral treatment as symptoms get better. Intravenous fluids may be necessary to attain a good urine output.

In patients presenting for the first time with high degree fever, loin pain and tenderness, emergency renal ultrasound examination is essential to leave out an obstructed pyonephrosis. If this is present it is drained surgically by percutaneous nephrostomy.

Treatment of Recurrent UTI:

Pretreatment and post-treatment culture of urine are obligatory to substantiate the diagnosis and recognize whether recurrent infection is because of relapse or reinfection.

In relapse, investigations are done for search of a cause (e.g. stones or scarred kidneys), and the cause has to be eradicated if possible, for example by the removal of stones or the affected kidney. Intense or prolonged therapy with intravenous or intramuscular aminoglycoside for 7 days or oral antibiotics for 4-6 weeks is necessary. If this treatment fails, long term antibiotics are prescribed.

Reinfection denotes that the patient has a predisposition to periurethral colonization or poor bladder defense mechanisms. Contraceptive practice is enquired and the use of a diaphragm and spermicidal jelly is discouraged. Atrophic vaginitis should be recognized in postmenopausal womenand they are treated with estrogen supplement locally.

All patients must embark on prophylactic actions:

# At least 2 L daily fluid intake
#Passing urine at 2 to 3 hour intervals and double micturition if there is reflux.
#Visit toilet before bedtime and after sexual intercourse
#Avoid spermicidal jellies and bubble baths and other chemicals in bathwater
# Constipation to be avoided as constipation may impair bladder emptying.

Proof of impaired bladder emptying on excretion urography or, ultrasound requires urological evaluation. If UTI continues to recur, treatment for 6-12 months with low-dose prophylaxis (trimethoprim 100 mg, cotrimoxazole 480 mg, cefalexin 125 mg at night, or macrocrystalline nitrofurantoin) is necessary; it should be taken last thing at night when urine flow is low. An substitute for occasional attacks is instant self-treatment with a conventional antibiotic for 3-5 days. When infection is clearly linked to sexual intercourse, a single dose of macrocrystalline nitrofurantoin following intercourse usually lessen the total drug requirement for prophylaxis. Intravaginal oestrogen therapy is beneficial in reducing the number of attacks of UTI in postmenopausal women. Cranberry juice is said to be beneficial in reducing the risk of symptoms and reinfection by 12-20% but studies are inadequate.

How UTI Occurs?
Complicated, Uncomplicated, recurrent and relapsing UTI
Symptoms and diagnosis of UTI
Treatment of UTI
Special types of UTI

What are Complicated, uncomplicated, recurrent and relapsing UTIs?

Complicated and uncomplicated urinary tract infection

It is essential to differentiate between UTI occurring in patients with functionally normal urinary tracts and in those with abnormal tracts.

In functionally and anatomically normal urinary tracts with normal renal imaging persistent or recurrent infection rarely results in serious kidney damage. These are categorized as uncomplicated UTI.

Abnormal urinary tracts means tracts with stones, or associated diseases such as diabetes mellitus which themselves result in kidney damage, may be made worse with infection. These are categorized as complicated UTI.

UTI, particularly with Proteus, may help to form stone in the urinary tract. The blend of infection and obstruction results in severe, sometimes very fast, kidney destruction (obstructive pyonephrosis) and is a most important cause of Gram-negative septicemia.


Reinfection and relapsing urinary tract infection:

When UTI is recurrent it is essential to differentiate between relapse and re infection.

Relapse is diagnosed by recurrence of bacteria in the urine and the same organism is found within 7 days of completion of antibacterial treatment and denotes failure to wipe out infection. This occurs usually in conditions such as stones, scarred kidneys, polycystic disease or bacterial prostatitis.

Reinfection is when bacteriuria is not found following completion of the drug therapy for at least 14 days, usually longer period, followed by recurrence of infection either with the same or different bacteriae. This is not because of failure to eliminate infection, but is due to reinvasion of a vulnerable urinary tract with new organisms. More or less 80% of recurrent infections are the result of reinfection.

How UTI Occurs?
Complicated, Uncomplicated, recurrent and relapsing UTI
Symptoms and diagnosis of UTI
Treatment of UTI
Special types of UTI