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8Nicolle LE, Harding GKM, Preiksaitis J et al: The association of urinary tract infections with sexual intercourse.
9Hooton TM, Scholes D, Hughes JP et al: A prospective study of risk factors for symptomatic urinary tract infection in young women. 10Jordan PA, Irvani A, Richard GA et al: Urinary tract infection caused by Staphylococcus saprophyticus. 11Boscia JA, Abrutyn E, Kaye D: Asymptomatic bacteriuruia in elderly persons: Treat or do not treat? 15Raz R, Gennesin Y, Wasser J et al: Recurrent urinary tract infections in postmenopausal women. 19Svanborg-Eden C, Hanson LA, Jodal U et al: Variable adherence to normal human urinary tract epithelial cells of Escherichia coli strains associated with various forms of urinary tract infection. 22Kinane DF, Blackwell CC, Brettle RP et al: ABO blood group, secretor state, and susceptibility to recurrent tract infection in women. 23Lamberg H, Adergren B, Leffler H et al: Influence of blood group on the availability of receptors for attachment of uropathogenic E. 24Baorto DM, Gao Z, Malaviya R et al: Survival of FimH-expressing enterobacteria in macrophages relies on glycolipid traffic.
25Handley MA, Reingold AL, Shiboski S et al: Incidence of acute urinary tract infection in young women and use of male condoms with and without nonoxynol-9 spermicides.
26Scholes D, Hooton TM, Roberts PL et al: Risk factors for recurrent urinary tract infection in young women. 29Gallagher DJA, Montgomerie JZ, North JDK: Acute infections of the urinary tract and the urethral syndrome in general practice. 30Stamm WE, Counts GW, Running KR et al: Diagnosis of coliform infection in acutely dysuric women.
33Beer JH, Vogt A, Neftel K et al: False positive results for leucocytes in urine dipstick test with common antibiotics. 34Bent S, Nallamothu BK, Simel DL et al: Does this woman have an acute uncomplicated urinary tract infection? 35Norrby SR: Short-term treatment of uncomplicated lower urinary tract infections in women. 36Hooton TM, Stamm WE: Management of acute uncomplicated urinary tract infection in adults.
The abdominal cavity is covered by the abdominal wall comprising skin, subcutaneous tissue including variable amounts of fat, muscles and and inner abdominal lining known as the peritoneum. Intra-adominal abscess is an accumulation of pus within the abdominal cavity which causes generalized abdominal distension along with localized distension. Internal bleeding (intra-abdominal) may arise when there is a rupture of a blood vessel following trauma or related to an abdominal aortic aneurysm (AAA). Hernia is a weakening in the abdominal wall thereby allowing parts of organs to protrude through it. Gallbladder disease is any disorder affecting the gallbladder, its duct or the other bile ducts. Colon disease involving the upper part of the ascending colon, hepatic flexure and first half of the transverse colon may cause right upper quadrant distension.
Hepatomegaly mainly causes distension most prominently in the right upper quadrant (RUQ) but if it is severe it may extend to the left upper quadrant (LUQ). Kidney disease of the left kidney may occur for the same reasons as discussed above under the right kidney. Ask a Doctor Online Now!Pancreas problems may cause left upper abdominal quadrant distension but the head of the pancreas, which is the part most commonly affected with pancreatic diseases, sits in the middle of the abdomen.
Aorta problems (abdominal aorta) are more likely to cause distension in the middle of the abdomen.
This is the lower middle part of the abdomen, below the navel, and just above the external genitalia. Bladder disease particularly where there is severe inflammation of the bladder, a mass in the bladder or overdistension as is seen with bladder outlet obstruction often caused by bladder stones, bladder cancer and cystitis.
Prostate disease (men only) that may lead to suprapubic distension includes benign prostatic hypertrophy (enlarged prostate), prostatitis or prostate cancer. Uterus problems (women only) that may cause distension of the suprapubic region possibly extending up to umbilical region includes uterine fibroids or uterine cancer. The causes of the right and left lower abdominal quadrant are discussed together although some causes may be isolated more to one side. Appendicitis is the inflammation of the vermiform appendix – the small outpouching from the cecum of the large intestine.
Large intestine – severe constipation, flatus (gas), impacted feces, colitis, colon cancer or diverticulosis. Ask a Doctor Online Now!Please note that any information or feedback on this website is not intended to replace a consultation with a health care professional and will not constitute a medical diagnosis. Urinary tract infections are a serious health problem affecting millions of people each year. Different parts of the urinary tract system can develop specific symptoms if infection appears: If infection attacks the urethra (urethritis), the most common symptom is burning during urination. Any other disorder that suppresses the immune system raises the risk of a urinary infection.
Nearly 20 percent of women who have a UTI will have another one and 30 percent of those will have yet another.
Bilateral hydronephrosis is the enlargement (distention) of the urine collecting structures and pelvis of both kidneys. See related patient information handout on urinary tract infection in children, written by the authors of this article. Urinary tract infections in childhood: definition, pathogenesis, diagnosis, and management.
Diagnostic imaging in the evaluation of the first urinary tract infection in infants and young children. Risk factors in the development of early renal cortical defects in children with urinary tract infection.
Renal scarring following reflux and nonreflux pyelonephritis in children: evaluation with a 99m technetium-dimercaptosuccinic acid scintigraphy. Relationship among vesicoureteral reflux, P-fimbriated Escherichia coli, and acute pyelonephritis in children with febrile urinary tract infection. Diagnosis of acute pyelonephritis in children: comparison of sonography and 99m Tc-DMSA scintigraphy.
The management of urinary tract infections in children without urinary tract abnormalities.
Practice guideline for the management of infants and children 0 to 36 months of age with fever without source. The value of urinalysis in differentiating acute pyelonephritis from lower urinary tract infection in febrile infants. Identification of infants unlikely to have serious bacterial infections although hospitalized for suspected sepsis. Vesicoureteric reflux and videourodynamic studies: results of a prospective study after three years of follow-up.
Evolving concepts in the evaluation of the child with a urinary tract infection [Editorial].
Is there a single most appropriate imaging workup of a child with an acute febrile urinary tract infection? The intravenous urogram in the detection and evaluation of renal damage following urinary tract infection.
Vesicoureteral reflux: an accurate predictor of acute pyelonephritis in childhood urinary tract infection? Ambulatory care visits to physician offices, hospital outpatient departments, and emergency departments: United States, 1997.
A Reassessment of the Importance of Low-Count Bacteriuria in Young Women with Acute Urinary Symptoms. Kunin, MD, Department of Internal Medicine, The Ohio State University, Room M110 Starling Loving Hall, 320 West 10th Avenue, Columbus, OH 43210-1240. Lee Vosburgh and the staff at the Ohio State University Student Health Service for their help in conducting this study. Its walls are able to stretch and the entire stomach can distend to several times its size when empty. It can occur on its own or be a symptom of other functional bowel disorders like irritable bowel syndrome (IBS).
A large part of the stomach is tucked under the left rib cage but it does distend with eating and less commonly with drinking fluids.
The causes are largely the same as colon disease causing right upper abdominal distension as discussed above. It is usually free of bacteria, viruses, and fungi but does contain fluids, salts, and waste products. If infection enters to the bladder (cystitis), symptoms include pelvic pressure, lower abdomen discomfort and frequent, painful urination.
Girls could become prone to UTI’s through wiping back-to-front when they are first toilet-trained, which pulls stool into the vaginal area. This is especially likely if the kidney filters are immature, or if there are a lot of bacteria. Any abnormality of the urinary tract that obstructs the flow of urine (a kidney stone, for example) sets the stage for an infection.
Some women have UTI chronically – women who have had UTI about 3-4 times are on the risk to have it more. Although UTIs do not occur with as great a frequency in children as in adults, they can be a source of significant morbidity in children. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. Rational strategies have been devised for cost-effective treatment of lower UTIs and to change the usual inpatient treatment of UTIs.


This distention is usually not visible from the exterior as space within the abdominal cavity allows for the stomach to expand. Therefore the abdomen can expand with accumulation of fluid, blood, gas or any mass within the cavity.
Splenic flexure syndrome which is believed to be caused by trapped gas is an additional causative factor to consider. If the aneurysm ruptures then blood may accumulate within the abdomen (internal bleeding) thereby causing generalized distension.
Any part of the urinary system can become infected, but most infections involve the lower urinary tract – the urethra and the bladder. An infection occurs when bacteria cling to the opening of the urethra and begin to multiply. If bacteria move to the bladder and multiply (bladder infection) – it called cystitis. If infection reach the kidneys (acute pyelonephritis), symptoms include upper back and side (flank) pain, high fever, shaking and chills and nausea. Sexual intercourse seems to trigger an infection, although the reasons for this linkage are unclear.
Often, a UTI can be cured with 1 or 2 days of treatment if the infection is not complicated by an obstruction or other disorder. For reasons that are not yet completely understood, a minority of UTIs in children progress to renal scarring, hypertension and renal insufficiency.
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Fortunately, most UTIs are easily eradicated and for uncomplicated UTIs, there does not appear to be long-term medical consequences. It probably introduces bacteria into the introitus, and further from the introitus through the urethra into the bladder, and is thus a risk factor.8 Delayed postcoital voiding is a possible second factor, because bacteria are allowed to remain and proliferate in the bladder. The entire abdomen may distend with fluid and gas or there may be localized distension (protrusion) with masses. Stomach bloating therefore may also refer to fullness in the stomach area, often felt after overeating or with indigestion. If the infection is not treated promptly and properly – bacteria can travel further up the ureters to multiply and infect the kidneys.
One factor may be that a woman’s urethra is short, allowing bacteria quick access to the bladder. Still, many doctors ask their patients to take antibiotics for a week or two to ensure that the infection has been cured. There are no symptoms in the fetus. In the newborn, any urinary tract infection is reason to suspect some type of obstructive problem in the kidney.
Clinical presentation of UTI in children may be nonspecific, and the appropriateness of certain diagnostic tests remains controversial. Recognizing and addressing these associated factors are essential in treating breakthrough UTI. For the missing item, see the original print version of this publication.Follow-up and ChemoprophylaxisA urine culture should be obtained three to seven days after the completion of treatment to exclude relapse. Strategies for managing recurrent infections are highly effective and are presented in this chapter. Theoretically, local immune defense mechanisms can overcome a small concentration of recently introduced bacteria, but infection can ensue when bacteria are allowed to grow to large concentrations by delayed voiding. As the bacterial count increased, the association between these organisms and symptoms increased, and a step-wise increase occurred in the frequency and magnitude of pyuria, but the specific gravity and urine creatinine levels remained unchanged. Yet the stomach only occupies a small portion of the abdominal cavity, mainly sitting in the left upper quadrant. Also, a woman’s urethral opening is near sources of bacteria from the anus and vagina. Longer treatment is also needed by patients with infections caused by Mycoplasma or Chlamydia. The diagnostic work-up should be tailored to uncover functional and structural abnormalities such as dysfunctional voiding, vesicoureteral reflux and obstructive uropathy.
A study in girls showed that treatment of voiding dysfunction combined with double antimicrobial prophylaxis was significantly successful in preventing breakthrough UTI.20Voiding DysfunctionVoiding dysfunction is a general term encompassing several patterns of detrusor instability and incomplete bladder emptying seen on urodynamic testing. However, data are lacking to prove urination after intercourse is an efficacious strategy to prevent UTI.9 A third factor is a recent UTI, because approximately 27% of women with an initial episode of cystitis have recurrent infection.
The most serious consequences can occur if a urinary tract infection spreads to the kidneys. A more aggressive work-up, including renal cortical scintigraphy, ultrasound and voiding cystourethrography, is recommended for patients at greater risk for pyelonephritis and renal scarring, including infants less than one year of age and all children who have systemic signs of infection concomitant with a UTI. Although vesicoureteral reflux is associated with renal scarring,7 its role in the pathogenesis of pyelonephritis and renal scarring is not fully understood.8 Findings from one study9 showed that scars formed in 40 percent of refluxing kidneys and 43 percent of nonrefluxing kidneys. It is often associated with daytime enuresis and constipation.20 Patients with otherwise unexplained recurrent UTI, especially in the setting of daytime enuresis or constipation, may merit urodynamic testing. By uncovering UTI and associated disorders, the goal of preventing renal infections, renal insufficiency, hypertension and end-stage renal disease can be realized.In any child with systemic signs of illness, treatment with parenteral antibiotics should be initiated, and after clinical improvement, therapy should be switched to oral antibiotics for 10 to 14 days. Some UTIs tend to cluster in time in the same individual from a persistent focus, but 90% of recurrent UTIs appear to be a newly reintroduced infection with new bacteria, occurring months apart.10 Diaphragm and spermicide use, which constitute the fourth risk factor, increase the risk of UTIs by killing H2O2-producing Lactobacillus while having no effect on Escherichia coli. Antibiotic prophylaxis is used in patients with reflux or recurrent UTI who are at greater risk for subsequent infections and complications.Urinary tract infection (UTI) is defined as the presence of bacteria in urine along with symptoms of infection. Children with voiding dysfunction are at increased risk for the development of vesicoureteral reflux and UTI.
Diagnostic imaging with ultrasound and renal cortical scintigraphy should be considered to document the presence of pyelonephritis or renal scarring; voiding cystourethrography should be performed when the urine is sterile and the patient is clinically improved. The low counts could not be explained by dilution of the urine or failure of the bacteria to grow well in the patients' urine.
Further management is dictated by the clinical course and findings on medical imaging (Figure 2a).In all patients less than five years of age with no systemic signs and in boys over age five with no systemic signs, treatment with oral antibiotics should be carried out for 10 to 14 days. These findings suggest that the infection was not established in the bladder urine and that low-count bacteriuria might be an early phase of urinary tract infection. Afterward, diagnostic imaging with ultrasound and voiding cystourethrogram should be considered.
Further management is dictated by findings on diagnostic imaging and clinical course (Figure 2b).In girls over five years of age with no systemic signs, treatment with oral antibiotics should be carried out for seven to 10 days. The last risk factor is use of selected antimicrobial agents, which also appears to alter the vaginal microflora and facilitate the survival of uropathogenic E. Diagnostic imaging in these patients is not necessary with the first UTI but may be indicated in cases of recurrent UTI.
Staphylococcus saprophyticus accounts for 5–15% of uncomplicated UTIs, and most infections with S.
However, if age older than 65 years is the only risk factor, the bacterial pathogens differ only slightly from those in young women.
The proximity of the urethra to the vagina and rectum allows fecal flora (with coliforms such as uropathogenic E. A genetic predisposition to UTIs is also suggested by findings of an increased risk of UTI and increased epithelial binding of E.
Even without these mechanisms, an abundant reservoir of bacteria is present to colonize the periurethral area and cause recurrent ascending UTIs.
In healthy women, pyelonephritis is almost always caused by bacteria with virulence factors.Several host defense mechanisms protect against infection.
Bacteria are inhibited in urine, which is acidic and has a high urea level and high osmolality.
The renal cortex is resistant to infection, whereas the renal medulla is very susceptible, because high urine osmolality inhibits leukocyte migration and phagocytosis.
A summary of potential interactions between behavior, host characteristics, and bacterial virulence factors are shown in Figure 1.
A small inoculum of bacteria into the bladder usually does not cause infection, but a large inoculation of bacteria, particularly fimbriated virulent uropathic strains in nonsecretor women, leads to UTI.
Additionally, use of nonoxynol-9, male condoms, and particularly nonoxynol-9 coated condoms,25 poor personal hygiene, and frequency of sexual intercourse contribute to the increased susceptibility to UTIs. Lastly, women of any age are at increased risk for UTI after antibiotic use.4CATEGORIES OF URINARY TRACT INFECTIONS AND CLINICAL MANIFESTATIONS IN ADULT WOMENA broad spectrum of anatomic levels and clinical manifestations of UTI that can be categorized separately (Table 1) are useful in choosing appropriate antibiotic therapy.
Tables 2 and 3 present a guide for differentiating acute pyelonephritis, acute uncomplicated UTI, urethritis, and vulvovaginitis.Acute uncomplicated UTI refers to a bacterial infection of the bladder that causes the abrupt onset of severe symptoms in a non-pregnant woman with a normal urinary tract and no underlying medical complications. Persistent cystitis is an infection that never completely resolves, and cultures remain positive for the same organism and strain.The definition of complicated UTI has expanded over time.
Originally, it referred to infections complicated by urologic disorders such as urinary calculi or abnormal anatomy of the urinary tract.
Functional abnormalities include detrusor hyperreflexia in patients with cerebrovascular accidents, hypotonic bladder that impedes complete bladder emptying in patients with multiple sclerosis, spinal cord injury, diabetes, or outlet obstruction that leads to elevated postvoid residual urine volumes or necessitates prolonged catheterization. Recognizing host conditions that complicate UTIs is important because antibiotic resistance occurs more often, response to treatment is less rapid, and additional infectious complications occur more readily. The clinical symptoms are often more gradual in onset and more nonspecific than those in acute uncomplicated UTI.Acute pyelonephritis is a clinical term used to describe the syndrome of acute illness with fever, chills, and low-back or flank pain and tenderness combined with bacteriuria. The clinical syndrome of upper UTI probably represents an acute infectious inflammatory process evolving in the renal pelvis, parenchyma, or both.
Renal parenchymal involvement is implicated when white blood cell casts are present in the urine. Suprapubic aspiration avoids potential contamination of the midstream urine collection, but it is usually reserved for research studies.
Urethral catheterization also reduces contamination, but it causes patient discomfort, requires staff time, and thus is costly.
The midstream, clean-catch urine collection technique remains the most used method of specimen collection. Demonstration of pyuria in centrifuged urine is less accurate because of a lack of specificity from leukocytes in contaminating vaginal material. Hematuria, present in 40% to 60% of episodes of acute uncomplicated UTI, is a highly specific but not a sensitive indicator of UTI.


White blood cell casts are diagnostic of upper urinary tract infection.Urine dipstick tests are quick and readily available in most clinical settings. Unfortunately, leukocyte esterase activity is not as sensitive as microscopy or as specific as culture. Practitioners should be aware of the potential for false-positive dipstick tests for leukocyte esterase in patients already receiving antibiotics.33 The nitrite test depends on the ability of bacteria to reduce nitrates to nitrites, which are normally absent in urine.
The nitrite test is specific but has only 50–75% of the sensitivity of urine culture. Initial urine cultures are indicated in patients with diabetes, symptoms lasting longer than 7 days, catheter-related infection, recent UTI, pregnancy, functional or anatomic abnormality of the urinary tract, immunosuppression, recent urinary tract instrumentation, and age older than 65 years.
However, women with symptoms of acute uncomplicated UTI should receive one of the rapid tests to detect pyuria or bacteriuria and started on treatment without a culture, because the bacteria that cause acute uncomplicated UTI and their antimicrobial susceptibilities are so predictable. In women with symptoms of acute uncomplicated UTI, pretreatment cultures did not predict the outcome and were considered unnecessary.A detailed review article analyzing the diagnostic accuracy of the clinical assessment for acute uncomplicated UTI found that specific symptoms and, particularly, combinations of symptoms increase the probability of UTI diagnosis substantially. In fact, symptoms of dysuria and frequency without vaginal discharge or irritation raised the probability of UTI to more than 90%. Proposed algorithm for evaluating a woman with symptoms of acute urinary tract infection (UTI).
The US Prevention Services Task Force recommends screening for chlamydia for all women age 25 years or younger and women of any age with more than one sexual partner, a history of sexually transmitted disease, or inconsistent use of condoms.
These tests should be reserved for women with a history of childhood UTIs, relapsing UTIs, history suggestive of calculi or obstruction, or infection with painless hematuria.TREATMENTAntibiotic treatments are chosen after consideration of success rate in relation to duration of treatment, toxicity, effects on vaginal and bowel flora, antibiotic resistance, and cost. The recommended duration of treatment for acute uncomplicated UTI has varied from single-dose therapy to the traditional 7- to 10-day course. Fluoroquinolone therapy for 7 days or longer should be reserved for patients with complicated UTIs. Hospital admission is necessary for an uncomplicated episode of acute pyelonephritis with nausea, vomiting, or suspected sepsis.
Patients with complicated infection related to a catheter, urologic surgery, or renal tract abnormality also require hospitalization. The IDSA guidelines also addressed acute pyelonephritis in women.37 Parenteral therapy or oral therapy with fluoroquinolones is the first-line agent for moderate to severe pyelonephritis and can be initiated until culture results are available. The traditional approach to therapy with ampicillin or an extended-spectrum cephalosporin plus an aminoglycoside is an alternative, but the increased resistance of E.
A total of 14 days of antibiotic therapy is indicated for pyelonephritis to prevent recurrence.45 Persistent symptoms after 72 hours of antibiotic therapy usually require further investigation with ultrasonography or computed tomography to investigate for urinary tract obstruction or abnormalities or to detect renal abscess. Complicated cases of pyelonephritis may require longer courses of therapy and urologic consultation.Treatment of asymptomatic bacteriuria offers no benefit for most healthy, adult, nonpregnant women.
A recent double-blind placebo-controlled study showed treatment of ASB in diabetic women did not reduce the complications including the number of symptomatic UTIs or hospitalizations.49However, screening of and treatment for asymptomatic bacteriuria should be performed in women before urologic surgery, in pregnant women, and in patients with neutropenia or renal transplant. Preventive Services Task Force reaffirmed their recommendation that pregnant women continue to need screening for asymptomatic bacteriuria, but not other adults (including diabetics).51Many women have infrequent episodes of acute uncomplicated UTI, and approximately 3% experience recurrences often enough to consider prophylactic treatment. These patients often have a cluster of infections over a short time period and then have infection-free intervals of 6–12 months.52 A less common mechanism of relapse occurs from persistent infection with the same bacteria and strain, usually at close intervals.
Relapsing infections also may be associated with a complicating factor such as urinary tract abnormalities or calculi. Changing from a diaphragm and spermicide or condoms to a different form of contraception that does not include nonoxynol-9 may be effective in preventing infection.
Three antibiotic prophylactic treatment regimens are effective to reduce recurrent infections. First, if reinfection correlates with sexual intercourse, a single-dose antibiotic postcoital strategy can be used.54 Second, self-start intermittent therapy with either single-dose or 3-day therapy is a reasonable option for women with relatively infrequent infections (two to three times per year). Trimethoprim-sulfamethoxazole is an inexpensive choice of antibiotic for either of these strategies. The third strategy consists of continuous low-dose prophylaxis with trimethoprim, trimethoprim-sulfamethoxazole, cephalexin, nitrofurantoin, or norfloxacin and is highly effective in suppressing infections for women with frequent recurrences.55, 56 Therapy is usually continued for 6 months, but infections often recur after suppressive therapy is discontinued.
The etiologic agents of UTIs in pregnancy are the same as those of acute uncomplicated UTI in nonpregnant women. As early as 7 weeks' gestation, a physiologic hydroureter develops from the hormonal effects of progesterone, which causes ureteral atony, increased ureteral volume, and urinary stasis. Physiologic bladder changes, including decreased smooth muscle tone, increased capacity, and incomplete emptying, predispose pregnant women to vesicoureteral reflux and ascending pyelonephritis. Early pregnancy screening and treatment of asymptomatic bacteriuria prevents 70–80% of cases of pyelonephritis.Pyelonephritis is a potentially serious threat for both the mother and the fetus.
Pyelonephritis during pregnancy can lead to multiorgan dysfunction with hemodynamic (shock), hematologic (anemia, thrombocytopenia), renal (decreased creatinine clearance), and pulmonary (adult respiratory distress syndrome) effects.
Approximately 1% of pregnant women with acute pyelonephritis have respiratory insufficiency from alveolar capillary leak. Most cases result in tachycardia, increased respiratory rate, and dyspnea.78 Prompt chest x-ray and arterial blood gas analyses are indicated.
Thus, acute pyelonephritis in the mother can lead to severe neonatal consequences from early preterm delivery.
Potential mechanisms involved in preterm labor include maternal bacteremia and endotoxemia, which result in systemic levels of inflammatory mediators, including cytokines, which in turn lead to myometrial activity.Whether asymptomatic bacteriuria alone leads to premature labor or other adverse perinatal outcomes in women without symptomatic pyelonephritis have remained a controversial subject.
A greater frequency of amniotic fluid infection has been noted in women with bacteriuria compared with women without infection.84, 85 It is possible that cervicovaginal uropathic microorganisms can colonize and infect both the urinary and amniotic fluid compartments in the same patient, causing both UTI and premature labor and delivery. A midstream clean-catch voided urine specimen for culture remains the standard for initial urine testing. Sulfonamides, nitrofurantoin, ampicillin, cephalexin, and nalidixic acid are all considered safe for use in pregnancy. Sulfonamides should not be used at term or during labor because of the theoretical risk of kernicterus in the infant.
The sulfonamide can displace bilirubin from plasma albumin binding sites and lead to hyperbilirubinemia, but this risk is low with the presently available short-acting sulfonamides. Trimethoprim, a dihydrofolate reductase inhibitor, has been shown to have toxic effects in experimental animals, although no teratogenicity has been reported in pregnant humans. Tetracycline is contraindicated in pregnancy because of potential maternal liver damage and permanent discoloration of the deciduous teeth of the child.
Fluoroquinolones are to be avoided because cartilage abnormalities have been reported in animal studies.
Fosfomycin has not been shown to have teratogenic effects in animal studies, but few well-controlled studies have been performed in pregnant humans.
It is unclear whether shorter courses of therapy eradicate the vaginal reservoir of uropathogenic bacteria in pregnancy.
Antibiotic suppression is also recommended after two acute episodes of UTI in the same pregnancy.Pregnant women with acute pyelonephritis should be hospitalized. Intravenous fluids, urine output monitoring, and parenteral antibiotics are generally recommended. Urine and blood cultures should be obtained in all pregnant women suspected of having pyelonephritis before initiating antibiotic therapy. Response to parenteral antibiotics is usually rapid, with 85% of pregnant women becoming afebrile within 48 hours and 97% becoming afebrile within 4 days of initiating treatment. Intravenous antibiotics should be continued until the patient is afebrile and can tolerate oral medications.
An acceptable alternative to suppressive therapy is evaluation every 2 weeks in the clinic, with urine cultures and prompt treatment of asymptomatic bacteriuria.
Other independent risk factors linked to catheter-associated bacteriuria include lack of antibiotic use, diabetes mellitus, absence of use of a urinometer, microbial colonization of the drainage bag, indications for catheter other than surgery or output measurement, abnormal serum creatinine, and errors in catheter care.105Aerobic Gram-negative rods account for most catheter-associated UTIs. Overall, Enterobacteriaceae, pseudomonads, and enterococci account for most of the infections. Candidal infections may be isolated in the urinary tract, particularly when antibiotics are in use and in the intensive care unit setting.Bacteria may take different routes to enter the catheterized urinary tract. The first route is direct introduction of periurethral microorganisms at the time of catheterization or instrumentation. With proper sterile catheterization technique, this should be infrequent, and based on time of onset, most catheter-associated infections arise later during the period of catheterization. A second route is the intraluminal route, in which microorganisms have entered the collecting bag or some junction in the collecting tube and ascend into the bladder.103, 106 With the adoption of sterile closed drainage systems, the incidence of infection via the intraluminal route has been markedly reduced.
The third route appears to be responsible for the majority of catheter-associated infections and involves migration of periurethral organisms along the catheter-urethral interface into the bladder.107, 108 Organisms adhere to catheter surfaces and embed in a biofilm layer that consists of host factors such as fibrin, fibronectin, and a exopolysaccharide material. Indwelling catheters are often used to manage incontinence in hospitalized women, but incontinence can often be managed without a catheter.
The Agency for Health Care Policy and Research (AHCPR) Clinical Practice Guideline for Urinary Incontinence in Adults stresses the use of alternatives to indwelling catheterization.109 As mentioned previously, use of a closed sterile drainage system can significantly reduce the incidence of catheter-associated infections. Decreasing the duration of catheterization, using clean intermittent catheterization, inserting catheters aseptically, and maintaining gravity drainage of urine are all useful in preventing indwelling catheter infections. Symptomatic nosocomial UTIs from catheterization can range from mild cystitis to acute pyelonephritis or septicemia.118 Symptomatic infections should be treated, and it is preferable to remove the catheter and begin appropriate antimicrobial therapy. If catheterization is still required, consider clean, intermittent catheterization or placing a new, sterile closed drainage system, because bacteria may be sequestered in a biofilm on the catheter surface.
Removal of the catheter results in the clearance of candiduria in approximately one third of patients.
Repeated isolations or symptomatic infections can be treated with 2-day continuous amphotericin B bladder irrigation119 or oral fluconazole.The National Surgical Infection Prevention Project has reported a retrospective review of 35,904 Medicare inpatients undergoing major surgery. A total of 86% of patients had perioperative indwelling catheters and 50% had catheters longer than 2 days. Length of post-operative urinary catheterization is becoming a target for quality improvement initiatives.



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