Chapter 238

Identification and treatment of urinary tract infections (UTIs) is important not only for explaining and managing signs and symptoms such as fever and dysuria but also for preventing pyelonephritis and sepsis and long-term complications including hypertension, chronic renal disease, and renal failure. Recurrent UTI is often a herald for anatomic and functional abnormalities that are associated with chronic renal disease.1,2

Urinary tract infections may involve the urethra and/or bladder (lower urinary tract) and the ureters, renal pelvis, calyces, and/or renal parenchyma (upper urinary tract). Lower urinary tract infection is usually characterized by dysuria, frequency, urgency, and possibly suprapubic tenderness. The clinical manifestations of acute pyelonephritis may include fever, lumbar pain and tenderness, dysuria, urgency, and frequency in association with significant bacteriuria.

Recurrence of a urinary tract infection may be caused by a relapse or a reinfection. A relapse is a recurrence of the infection with the same infecting microorganism, sometimes as a result of inadequate therapy. A reinfection is a new infection caused by an organism that is different from the one responsible for the previous episode. Specific identification may require serotyping, pyocin typing, phage typing, antibiotic resistance, or genetic typing of the bacterium (eg, Escherichia coli), procedures that are not uniformly available to the clinician. These identification techniques may also be useful for associating individual incidents with hospital outbreaks of infection. The term chronic infection is sometimes used to describe (1) persistence of the urinary tract infection associated with the same organism for many months or years or (2) frequent recurrences over many months or years.

### Epidemiology

Urinary tract infections involve all age groups from neonates to geriatric patients. Studies involving routine suprapubic puncture in more than 1000 infants revealed the presence of bacteriuria in 0.1% to more than 1%3,4. Urinary tract infection is more common in males, with the majority of these infections occurring in uncircumcised infants. However, circumcision to prevent urinary tract infection is not warranted by the low frequency and usually mild nature of the disease. Premature infants have 2 to 3 times this rate of urinary tract infection. During preschool years, urinary tract infection is more common in girls (4.5%) than in boys (0.5%). Long-term surveillance studies of school children revealed persistent bacteriuria in 1.2% of girls and in 0.4% of boys. Each year an additional 0.4% of girls developed bacteriuria.5 Thus the overall prevalence in school-age girls approached 5%.5-7 These studies indicated that the peak incidence of urinary tract infection in children occurred between ages 2 and 6. White girls tended to have more frequent reinfections than black girls. The incidence of urinary tract infection in females of high school and college age is approximately 2%.

### Pathophysiology and Genetics

Adenovirus types 11 and 21 and the human papovavirus BK have been reported as causes of acute hemorrhagic cystitis.11-14 Symptomatic and ...

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