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Images flagella.jpg
  • 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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