General MedicineTier 1Disease (DEADMAN)

Urinary tract infection, urosepsis or pyelonephritis

Description

Spectrum: asymptomatic bacteriuria (usually no treatment) -> cystitis (lower tract) -> pyelonephritis (upper tract, systemic) -> urosepsis (septic shock)
Complicated UTI: structural/functional abnormality, male sex, pregnancy, catheter, immunosuppression, renal impairment - changes management threshold and duration

F>>M in younger adults (short urethra, sexual activity); risk equalises with age (prostatic disease in men)
Common cause of sepsis in the elderly, esp. with catheters or urinary retention

E. coli ~80% of community-acquired UTI; also Klebsiella, Proteus, Enterococcus, Staph saprophyticus (young women)
Ascending infection from periurethral/vaginal flora -> bladder -> ureters -> kidney
Catheter-associated - biofilm formation, often polymicrobial, higher resistance
Obstruction (stones, BPH, malignancy) predisposes to pyelonephritis and abscess

Cystitis: dysuria, frequency, urgency, suprapubic pain, +/- haematuria - clinical diagnosis, culture not always needed in uncomplicated cases
Pyelonephritis: fever, rigors, flank pain, costovertebral angle tenderness +/- lower tract symptoms
Urine MCS before starting empirical antibiotics for pyelonephritis/complicated UTI (unlike simple cystitis)
Urosepsis: qSOFA/SOFA criteria, blood cultures, lactate
Imaging (renal ultrasound/CT) if failure to respond in 48-72h, recurrent, or obstruction suspected

1. Uncomplicated cystitis

Trimethoprim or nitrofurantoin first-line (local resistance-dependent), short course (3-5 days)

2. Pyelonephritis

Oral fluoroquinolone or cephalexin if well enough for oral therapy; IV gentamicin + amoxicillin, or ceftriaxone if admitted/systemically unwell
Duration typically 7-14 days depending on agent and response
Analgesia, antipyretics, adequate hydration

3. Urosepsis/septic shock

Sepsis pathway - blood cultures, IV antibiotics within 1 hour, fluid resuscitation, source control (relieve obstruction - stent/nephrostomy if obstructed and infected)
An obstructed, infected kidney is a urological emergency - needs urgent decompression regardless of antibiotic response

4. Complicated/recurrent UTI

Investigate for structural cause, consider longer duration/broader cover
Recurrent UTI in women - post-coital prophylaxis, vaginal oestrogen in postmenopausal women, consider low-dose prophylactic antibiotics if severe

Urosepsis, renal/perinephric abscess, emphysematous pyelonephritis (esp. diabetics)
Chronic pyelonephritis/scarring with recurrent childhood UTI and vesicoureteric reflux
Struvite stones with urease-producing organisms (Proteus)

Uncomplicated cystitis - resolves rapidly with short-course therapy
Pyelonephritis - most improve within 48-72h of appropriate antibiotics; failure to improve mandates imaging for abscess/obstruction
Obstructed pyonephrosis untreated -> sepsis, renal loss - emergency decompression changes outcome

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