Urinary Tract Infection - Urgent Care

Decision

Lower UTI

Upper UTI

Background

Answer these 6 questions:

1. Is this patient’s symptom the result of a UTI, or could there be an alternative diagnosis?
• Do they have classic symptoms of acute cystitis? dysuria, frequency, urgency, and suprapubic discomfort
2. Does this patient have a lower or upper tract UTI?
• Upper UTIs are often distinguished from lower UTIs by the presence of systemic symptoms such as fever, nausea, vomiting, chills, and back pain. In practice, however, there is often considerable overlap between upper and lower UTIs, so clinicians must understand the wide spectrum of clinical manifestations of pyelonephritis.
• Percussion of the costovertebral angle and a rectal temperature in equivocal cases can detect an occult fever and aid in diagnosing pyelonephritis
• Fever is a common finding in pyelonephritis
• A retrospective cohort study of 304 patients from a single center showed that patients without fever were more likely to have other diagnoses, such as pelvic inflammatory disease, diverticulitis, or cholecystitis
• During influenza seasons and COVID-19 waves, there may be a temptation to prematurely diagnose viral infection in every patient with fever and myalgia. Avoid this pitfall, especially when cough and congestion are mild or absent.
• Consider that subclinical pyelonephritis is seen more often in patients with recurrent UTIs, prolonged symptoms ( >7 days duration), male sex, diabetes mellitus, pregnancy, immunosuppression, and advanced age
3. Is the patient possibly pregnant?
4. Has there been any exposure to STIs?
5. Is this an uncomplicated or complicated UTI?

Uncomplicated UTI (culture not necessary)

Lower UTI (cystitis) in nonpregnant female

Complicated UTI (obtain culture)

Upper UTI (pyelonephritis)

Male sex

Pregnancy

Moderate or severe diabetes mellitus

Anatomic abnormalities

Cancer, chemotherapy, immunosuppression

Impaired micturition

Catheter, stent, or tube in urinary system

Obstructive ureteral stone

Hospital-associated UTI

Treatment failure

6. Does this patient require ED transfer for more extensive evaluation and/or advanced imaging?
• Patients with severe sepsis or shock should be identified early
• Recognize the signs of systemic inflammatory response syndrome (SIRS), which include hyperthermia/hypothermia, leukocytosis, leukopenia, tachycardia, and tachypnea.
• The elderly, the immunocompromised, and patients with comorbid conditions (eg, indwelling catheters or urethral obstruction).
• Early ED transfer is recommended in suspected UTI patients with significant tachycardia; patients with hypotension or altered mental status warrant EMS activation for transport.

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Urinary Tract Infections: Urgent Care Management

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Full UTI Pathway

Lower UTI

Upper UTI