Most UTIs manifest as acute uncomplicated bacterial cystitis, and women experience most of these episodes. Escherichia coli causes up to 90% of cases, with the rest probably caused by Staphylococcus saprophyticus. Other causative organisms include Proteus mirabilis, enterococci, and Klebsiella (Fihn, 2003). To have "uncomplicated cystitis," women must have no underlying urinary tract abnormalities or immune compromise (Bent et al., 2002).
Dysuria, frequency, and urgency are the classic clinical triad. The condition most commonly mimicking UTI is vaginitis. Other conditions have been described (see Dysuria). Patients may also experience back or flank pain and supra-pubic abdominal pain. Dipstick urinalysis may show leukocyte esterase or nitrite or may be heme positive. Microscopic analysis should assess for pyuria, hematuria, and bacteriuria. The gold standard for diagnosis is urine culture.
Women presenting with at least one UTI symptom have a 50% chance of having a UTI. The combination of dysuria and frequency without vaginal symptoms increases the chance to 90% (likelihood ratio, 24.6). Four symptoms significantly increase the chance of UTI—dysuria, frequency, hematuria, and back pain (Bent et al., 2002). Nitrite-positive or leukocyte esterase-positive dipsticks are the most accurate tests, but cannot rule out a UTI.
Antibiotics are the mainstay of treatment, usually for 3 days (Table 40-11). A shorter duration is as effective as longer therapy for most women, including older adult women (Lutters and Vogt, 2002; Milo et al., 2005). In the southeastern and southwestern United States, there is growing E. coli resistance to TMP-SMX, leading some to recommend that this should no longer be first-line treatment for UTI. However, many women treated with TMP-SMX who have a resistant organism on culture achieve clinical cure (Fihn, 2003). Compared with quinolones' propensity for resistance, TMP-SMX is still a reasonable first choice for many patients, and family physicians should base treatment choices on documented local resistance patterns. If resistance to TMP-SMX exceeds 20%, an alternative treatment should be employed (Nicolle, 2008).
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