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Snapshot
  • A 24-year-old woman at 8 weeks of gestation presents to her obstetrician for increased urinary frequency, dysuria, and some suprapubic pressure for the past few days. She has a history of spontaneous abortions. On physical exam, she has suprapubic tenderness to palpation and right costovertebral tenderness. A rapid urine dipstick shows nitrite, leukocyte esterase, and urease positivity.  She is started on an antibiotic that is safe for pregnant women.
Introduction
  • Classification
    • Proteus spp.
      • P. mirabilis (most common, both community-acquired and nosocomial)
      • P. vulgaris (nosocomial)
      • urease-positive, oxidase-negative, and non-lactose fermenting gram-negative bacillus
    • causes urinary tract infections (UTI)
  • Epidemiology
    • incidence
      • very common
    • demographics
      • women > men
    • risk factors
      • urinary catheter
      • urinary tract obstruction
      • living in nursing home
      • hospital admission
      • immunocompromised status
  • Pathogenesis
    • increased inoculum size is correlated with risk of infection
    • the bacteria attach to the urinary tract endothelium
    • can produce endotoxin that can lead to sepsis
    • hydrolyzes urea to ammonia, which alkalinizes the urine
  • Associated conditions
    • struvite kidney stones
  • Prognosis
    • mortality is low with treatment
Presentation
  • Symptoms
    • dysuria
    • urinary frequency
    • flank pain
  • Physical exam
    • costovertebral tenderness
    • suprapubic tenderness
Imaging
  • Abdominal computed tomography (CT)
    • indication
      • evaluate for kidney stones
    • findings
      • radiopaque stones
Studies
  • Urine culture
    • “swarming” motility on agar plate
  • Urine dipstick
    • leukocyte esterase positive
    • nitrite positive
    • urease positive
    • pH alkaline
  • Making the diagnosis
    • based on clinical presentation and laboratory studies
Differential
  • E. coli urinary tract infection
    • distinguishing factor
      • urinalysis does not show urease positivity
Treatment
  • Management approach
    • final choice of antibiotics depends on whether or not a UTI is uncomplicated vs complicated and the sensitivities of cultured bacteria
    • uncomplicated UTI
      • acute cystitis or pyelonephritis in outpatient women who are not pregnant and do not have anatomic abnormalities or instrumentation within the urinary tract
    • complicated UTI
      • patients who do not meet uncomplicated UTI criteria
  • Medical
    • trimethoprim/sulfamethoxazole or nitrofurantoin
      • indication
        • first-line for uncomplicated UTI
          • second-line agents include fluoroquinolone or β-lactam
    • fluoroquinolone
      • indication
        • first-line for acute uncomplicated pyelonephritis
    • nitrofurantoin or cephalosporins
      • indication
        • pregnant women
Complications
  • Urosepsis
  • Struvite stones
 

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