Urinary tract infections (UTIs) occur when microbes invade the otherwise sterile environment of the urinary tract system. The urinary tract system includes the urethra, bladder, ureters and kidneys. The spectrum of UTIs involves infection of any part within this system. UTIs are a common diagnosis in most hospitals across all age groups and more so in pregnant mothers. Progress has been made over the years regarding the management of the UTIs based on symptomatic presentation and laboratory findings.
UTIs can be diagnosed on the basis of symptoms alone. The most common diagnostic presentation of UTIs includes frequency, urgency, dysuria, and vaginal discharge. While symptomatic presentation suggests the presence of UTI, it is necessary to carry out further tests to confirm the diagnosis (Schmeimann et al., 2010). A dipstick urinalysis is an essential investigation. Even in the absence of symptoms, a negative dipstick does not rule out the presence of a UTI as long as the patient has symptoms suggestive of UTI. In such a situation, it is necessary for further tests with a higher specificity. The urinary nitrites test is a more specific test which confirms the presence of nitrites in urine suggesting infection by a gram-negative bacteria (Schmeimann et al., 2010). However, urinary culture remains the gold standard for the diagnosis of UTI. Urinary culture allows the growth of microbes, ruling in the presence of these organisms in the urinary tract.
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UTI treatment can be initiated in the presence of symptoms without a confirmatory laboratory diagnosis. While positive laboratory results suggest a high probability for UTIs, initiation of treatment is recommended for patients whose symptoms are highly suggestive of a urinary tract infection (Barber et al., 2013). Diclofenac has been used in the symptomatic relief of UTIs but was found to have a higher risk for causing pyelonephritis but lowered the need for antibiotic therapy. UTI treatment based on symptoms is mostly empirical and targets the most common organisms within a particular region. This is because the specific pathogen causing disease has not been confirmed. The common medications used in the symptomatic treatment of UTIs include nitrofurantoin monohydrate/macrocrystals, trimethoprim-sulfamethoxazole and fosfomycin (Barber et al., 2013). These medications have proven effective in eliminating infection in a majority of patients. However, due to increased use, there is increasing resistance of microbes towards the medications.
UTIs can also be managed based on laboratory results. A positive result showing leucocytes in urine is suggestive of a bacterial infection, causing inflammation within the urinary tract (Schmeimann et al., 2010). It, however, does not specify the specific pathogen responsible for the inflammation. As a result, treatment of such patients is empiric, similar to treatment based on symptoms. It is, therefore, still essential to carry out a urine culture to determine specific pathogens to administer targeted treatment. This will aid in the reduction of resistance towards antimicrobials.
Urine culture is the gold standard choice of investigation for UTIs (Schmieman et al., 2010). This test isolates specific disease-causing pathogens, paving the way for a particular treatment. This way, results from a urine culture are followed by treatment targeting the particular pathogen. The most common organisms, such as Escherichia Coli are responsive to ciprofloxacin and nitrofurantoin (Barber et al., 2013). If a beta-lactamase-producing organism is isolated, recommended treatment includes: - fosfomycin, nitrofurantoin, fluoroquinolones, cefepime, and carbapenems (Barber et al., 2013). For infections caused by Enterobacteriaceae , management options include the use of the same antibiotics with the additional options of cefoxitin, aminoglycosides and ceftolozane-tazobactam (Bader et al., 2017). With increasing use of antibiotics comes increasing cases of resistance. Treatment options for multi-drug resistant pseudomonas include carbapenems, aminoglycosides, fluoroquinolones, and ceftazidime (Bader et al., 2017). Treatment is similar for both complicated and uncomplicated UTIs, based on the organism isolated. However, treatment duration is three days for uncomplicated UTIs and seven to fourteen days for complicated UTIs. It is, therefore, prudent for healthcare professionals to carry out urine cultures in symptomatic patients to narrow down the management options. Specific treatment reduces antibiotic duration and the chances of development of antibiotic resistance.
References
Bader, M. S., Loeb, M., & Brooks, A. A. (2017). An update on the management of urinary tract infections in the era of antimicrobial resistance. Postgraduate medicine , 129 (2), 242-258.
Barber, A. E., Norton, J. P., Spivak, A. M., & Mulvey, M. A. (2013). Urinary tract infections: current and emerging management strategies. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America , 57 (5), 719–724. https://doi.org/10.1093/cid/cit284
Schmiemann, G., Kniehl, E., Gebhardt, K., Matejczyk, M. M., & Hummers-Pradier, E. (2010). The diagnosis of urinary tract infection: a systematic review. Deutsches Arzteblatt international , 107 (21), 361–367. https://doi.org/10.3238/arztebl.2010.0361
