ROJoson’s Notes on Urinary Tract Infections

This webpage contains my notes on Urinary Tract Infection.




The urinary tract includes the kidneys (which filter the blood to produce urine), the ureters (the tubes that carry urine from the kidneys to the bladder), the bladder (which stores urine), and the urethra (the tube that carries urine from the bladder to the outside) (figure 1). Urinary tract infections happen when bacteria get into the urethra and travel up into the bladder. If the infection stays just in the bladder, it is a called a bladder infection, or “cystitis.” If the infection travels up past the bladder and into the kidneys, it is called a kidney infection or “pyelonephritis.”

Bladder infections are one of the most common infections, causing symptoms of burning with urination and needing to urinate frequently. Kidney infections are less common than bladder infections, and they can cause similar symptoms, but they can also cause fever, back pain, and nausea or vomiting.

Both bladder and kidney infections are more common in women than men. Most women have an uncomplicated bladder infection that is easily treated with a short course of antibiotics. In men, bladder infections may also affect the prostate gland, and a longer course of treatment may be needed. Kidney infections can also usually be treated at home with antibiotics, but treatment typically lasts longer. In some cases, kidney infections must be treated in the hospital.



PhilHealth Standards (2016)
Policy statements on the Diagnosis and Management of Urinary Tract Infection in Adults as reference by the Corporation in ensuring quality of care
PhilHealth Circ 2016-002
Patients of Urinary Tract Infection (UTI) must be confined at least four days before they can file claims with state-owned fund PhilHealth.
Urinary tract infection (UTI) is an infection that affects any part of the urinary tract. If the infection affects the lower urinary tract it is known as simple cystitis (a bladder infection) while if it affects the upper urinary tract it is known as pyelonephritis (kidney infection).
To make a clinical diagnosis of urinary tract infection (UTI), one or more of the following should be sought in the patient’s history:
  • acute onset of dysuria
  • frequency
  • urgency
  • hematuria
  • lower abdominal pain
  • flank pain
  • nocturia
  • fever with/without chills
  • flank pain
  • costovertebral angle tenderness
  • absence of vaginal discharge and/ or irritation in the presence of the above clinical signs and symptoms
1. Routine urinalysis is not needed to confirm the diagnosis of UTI presenting with one or more of the above symptoms of UTI in the absence of vaginal discharge.
2. Urinalysis or urine gram stain may be requested for the following conditions: acute uncomplicated pyelonephritis, acute pyelonephritis in pregnancy, acute uncomplicated cystitis in women with gynaecological (vaginal) signs and symptoms, and uncomplicated cystitis in men.
3. Urine culture and sensitivity may be requested for patients with worsening signs and symptoms, for screening asymptomatic bacteriuria among pregnant women, for acute uncomplicated pyelonephritis, acute pyelonephritis in pregnancy and suspected complicated UTI. .
4. Following up urine culture is not necessary for patients clinically responding to therapy.
5. Renal ultrasound and plain abdominal X-ray should be done only in the presence of gross hematuria during UTI episode, obstructive symptoms, clinical impression of persistent infection, infection with urea-splitting bacteria, history of pyelonephritis, history of or symptoms suggestive of urolithiasis, history of childhood UTI and elevated serum creatinine.
6. Blood cultures are NOT routinely recommended except in patient with signs of sepsis.
1. The following are the indications for admission:
  • In acute uncomplicated pyelonephritis in women who are unable to accept oral hydration or take oral medications
  • In acute pyelenephritis in pregnant women;
  • In complicated UTI;
  • In urinary candidiasis patients who are under critical care, neutropenic, post-renal transplant, or about to undergo neurological procedures;
  • Severe illness with high fever, severe pain, marked debility, and signs of sepsis
2. The recommended length of stay (LOS) for uncomplicated UTI should be minimum of 96 hours (12 hours of IV antibiotics and 24 hours switch to oral) to provide sufficient time for proper evaluation of patient’s response to therapy. Otherwise, the claim shall be denied.
1. The aminopenicillins (ampicillin or amoxicillin) and first generation cephalosporins are NOT recommended because of the high prevalence of resistance and increased recurrence rates in patients given these beta-lactams.
2. The TMP-SMX is NOT recommended for empiric treatment but it can be used when the organism is found to be susceptible on urine culture and sensitivity.
3. For patients with acute uncomplicated pyelonephritis requiring hospitalization, ceftriaxone, fluoroquinolones, or aminoglycosides are recommended as empiric first-line treatment (see annexA).
4. Intravenous antibiotics can be shifted to any of the listed oral antibiotics once the patient is afebrile and can tolerate oral drugs. The choice of continued antibiotic therapy should be guided by the urine culture and sensitivity results once available.
5. Carbapenems and piperacillin-tazobactam should be reserved for acute pyelonephritis caused by multi-drug resistant organisms that are susceptible to either drug.
6. Nitrofurantoin macrocrystal (100 mg BID for five days) is recommended as the first line treatment for acute uncomplicated cystitis due to its high efficacy, minimal resistance and minimal adverse effects (see annex B). 
1. Recurrent UTI is defined as 2 or more episodes of uncomplicated UTI in 6 months or more traditionally, as three or more 3 positive cultures within the preceding 12 months.
2. Urinalysis and midstream urine culture and sensitivity should be performed with the first presentation of symptoms in order to establish a correct diagnosis of recurrent UTI.
3. Prophylaxis for recurrent UTI should NOT be undertaken until a negative culture of 1 to 2 weeks after treatment has confirmed eradication of the urinary tract infection.
4. Start antibiotic therapy with a 3-day treatment dose antibiotic at the onset of symptoms for the treatment of recurrent uncomplicated UTI.
The diagnostic tests and therapeutic interventions mentioned in this document shall be expected to be performed in health care facilities wifu service capability as reflected in their licensed by the Bureau of Health Facilities and Services (BHFS) of the Department of Health (DOH). Willie HCis without such service capability, they shall not be required to be performed. However, health outcomes of patients shall be monitored by the Corporation using the following monitoring tools but not limited to: facility visits, domiciliary investigations, chart review, and others as appropriate.
Furthermore, the health care provider shall be bound by the provisions of the Performance Commitment and subject to the rules on monitoring and evaluation of performance as provided in Phi!Health Circular No. 31 s-2014 (HC P-PAS).
This Circular shall be reviewed periodically and as necessary.
Signed: January 12, 2016

Annex A. Empiric Treattnent Regimens for Uncomplicated Acute Pyelonephritis (Adapted from PSMID 2013 Update)

Antibiotics Dose, Frequency, Duration
Primary Ciprofloxacin 500 mg BID for 7-10 days
Ciprofloxacin extended release 100 mg OD for 7 days
Levofloxacin 250 mg OD for 7-10 days
750 mg OD for 5 days
Ofloxacin 400 mg BID for 14 days
Alternative Cefixime 400 mg OD for 14 days
Cefuroxime 500 mg BID for 14 days
Co-amoxiclav (when GS shows gram+ organisms) 625 mg TID for 14 days
Primary Ceftriaxone 1 -2 gm q 24 h
Ciprofloxacin 200-400 mg q 12 h
Levofloxacin 250-750 mg q 24 h
Ofloxacin 200-400 mg q 12 h
Amikacin 15 mg/kg BW q 24 h
Alternative Ampicillin-sulbactam (when GS shows gram+ organisms) 1.5 grams q 6 h
Reserved for MDROs Ertapenem (if ESBL prevalence >10%) 1 gram q 24 h
Piperacillin-Tazobactam 2.25 -4.5 grams q 6-8 h


.Annex B. Antibiotics that can be used for Acute Uncomplicated Cystitis (Adapted with modification from PSMID 2013 Update)

Antibiotics Dose, Frequency, Duration
Primary Nitrofurantoin macrocrystals 100 mg QID for 5 days PO
Alternative Ofloxacin 200mg BID for 3 days PO
Cirofloxacin 250mg BID for 3 days PO
Cirofloxacin extended release 400mg OD for 3 days PO
Levofloxacin 250mg BID for 3 days PO
 Norfloxacin 400mg BID for 3 days PO
Co-amoxiclav 625mg BID for 7 days PO
Cefuroxime 250mg BID for 7 days PO
Cefixime 200mg BID for 7 days PO
Only if with proven susceptibility Trimethoprim-sulfamethoxazole (TMP-SMX) 160/800 mg BID for 3 days PO



Philippine Practice Guidelines Group in Infectious Diseases-Task Force on Urinary Tract Infections – 2004


Asymptomatic Bacteriuria and Recurrent UTI 2014 Guidelines
Scribd uploaded by Hedy Suico Galela
ROJoson’s Collated Notes
What is the urinary tract?

The urinary tract is the tubular system which transfers urine from the site of its production, kidneys. The urinary tract consists of bilateral ureters opening into the urinary bladder and the urethra which passes urine from the urinary bladder to the exterior. This tubular system makes a continuous passage for the urine flow.

The renal pelvis which receives urine from the renal tissue and to the ureters is known as the upper urinary tract. The urethra and the bladder storage is referred to as the lower urinary tract.

The urinary tract therefore includes the organ system primarily responsible for cleaning and filtering excess fluid and waste material from the blood. The organ system is called the urinary system and is made up of the following:

  • Kidneys
  • Ureters
  • Bladder
  • Urethra
Urinary tract infection is an infection of any of the parts of the urinary system.
  • Urethritis is inflammation / infection of the urethra, the tube that carries urine from the bladder out of the body.
  • Cystitis is inflammation / infection of the urinary bladder.
  • Ureteritis is inflammation / infection of the ureter.
  • Pyelonephritis is inflammation / infection of the kidney tissues, calyces, and renal pelvis.
Upper urinary tract infections: Upper urinary tract infection affects renal pelvises and the ureters.
Lower urinary tract infection: Lower urinary tract infection affects the urinary bladder and the urethra.
Infections of the urethra (urethritis) and the bladder (cystitis) are referred to as lower urinary tract infections. Involvement of the ureters and the kidneys (pyelonephritis) is referred to as upper urinary tract infections. The key difference between lower and upper urinary tract infections is determined by the anatomical involvements. However, there could be situations where the whole tract is infected causing pan urinary tract infections. Lower urinary tract infection can easily spread to involve upper tracts causing both upper and lower urinary tract infections together.
In the clinical practice of medicine, for all practical purposes, ureteritis is not treated separately unless the inflammation / infection is confined to the ureters.  Thus, rarely does ureteritis is being discussed as a distinct clinical entity. In clinical practice, the discussion or recognition is on urethritis, cystitis, and pyelonephritis as distinct clinical entities. As mentioned, however, the entire urinary system may be involved or just the lower and upper urinary tract.
Clinical cues for the diagnosis of UTI:
  • Urethritis – burning sensation with urination with or without discharge
  • Cystitis – painful urination, sensation of urgency with increased frequency, lower abdomen discomfort, blood in urine
  • Pyelonephritis – upper back and side (flank) pain with or without fever and chills

Some general info:


Upper urinary tract infections: Upper urinary tract infections are caused by gram negative organisms most of the times.

Lower urinary tract infection: Lower urinary tract infections can be caused by some sexually transmitted pathogen in additional to gram-negative bacilli and skin commensals.

Upper urinary tract infections: Upper urinary tract infections are more severe.
Lower urinary tract infection: Lower urinary tract infections are less severe.

Upper urinary tract infections: Upper urinary tract infections can be ended up with acute renal failure, renal abscesses, septicemia, and death, etc.
Lower urinary tract infection: Lower urinary tract infections usually do not lead to serious complications.



Problem-based Learning Issues:



Urine culture


Probability – Likelihood

Cost of medicines


Will continue to update this.


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