Urinary tract infections (UTIs) start with the colonization of uropathogens in the vaginal introitus or the urethral meatus. The colonization then moves up through the urethra into the bladder. This infection of the bladder and lower urinary tract is called cystitis. When an infection ascends into the upper urinary tract and the kidneys, it is called pyelonephritis. A UTI that extends beyond the bladder and includes a fever or other systemic symptoms is a complicated UTI. Complicated UTIs can lead to sepsis.
UTIs can be clinically categorized as either acute uncomplicated UTIs or acute complicated UTIs based on the extent and severity of the infection. This categorization directs the management of care and differs from other conventions.
Acute uncomplicated UTIs typically affect individuals, especially women, children, and elderly individuals who are otherwise healthy and have no structural or neurological urinary tract abnormalities.
An acute uncomplicated UTI is presumed to be confined to the bladder (cystitis), i.e., lower UTI with no signs or symptoms that suggest an upper tract or systemic infection.
Risk factors associated with cystitis include (Hooton & Gupta, 2021; Flores-Mireles et al., 2015):
Nonpregnant, premenopausal women who do not have a urologic abnormality are considered uncomplicated even with cystitis or pyelonephritis (Hooton & Gupta, 2021).
Acute complicated UTI has been defined as upper UTIs (pyelonephritis) associated with factors that compromise the urinary tract or host defense (Hooton & Gupta, 2021).
The term "acute complicated UTI" refers to an acute UTI with any of the following features, which suggest that the infection extends beyond the bladder (Hooton & Gupta, 2021):
By this above definition, pyelonephritis is an acute complicated UTI, regardless of patient characteristics. In the absence of any of the above symptoms, patients with a UTI should be considered to have acute simple cystitis, and thus the patient is managed differently.
Risk factors associated with acute complicated UTIs include (Hooton & Gupta, 2021):
In the U.S., 70 to 80% of acute complicated UTIs are attributable to indwelling catheters, accounting for one million cases/year.
Catheter-associated UTIs (CAUTIs) increases morbidity and mortality and are the most common cause of sepsis. Risk factors for developing a CAUTI include (Hooton & Gupta, 2021):
Genitourinary abnormalities may be associated with an acute complicated UTI (See Table 1). Blockage to a normal stream of urine decreases the flushing action of bacteria. Mechanisms of infection include (Hooton & Gupta, 2021):
The risk of infection varies with different abnormalities.
An acute complicated UTI occurs in people of any age group (Hooton & Gupta, 2021):
The typical presentation of UTI encompasses both cystitis with complicating features and pyelonephritis.
Signs and symptoms of cystitis include (Hooton & Gupta, 2021; McLellan & Hunstad, 2017):
Signs and symptoms of acute complicated UTI which suggest that infection has extended beyond the bladder include (Hooton & Gupta, 2021; McLellan & Hunstad, 2017):
Signs and symptoms of pyelonephritis classically include (Hooton & Gupta, 2021; McLellan & Hunstad, 2017):
Not all patients with acute complicated UTI present with clear symptoms localized to the urinary tract. For example (Hooton & Gupta, 2021; McLellan & Hunstad, 2017):
Patients with acute complicated UTI may be associated with severe morbidities, such as septic shock or death. However, patients may also present with (Hooton & Gupta, 2021):
Acute pyelonephritis can also be complicated (Hooton & Gupta, 2021):
Massive destruction of the kidney by granulomatous tissue, usually due to obstruction by renal stones, is xanthogranulomatous (Hooton & Gupta, 2021). Nonspecific signs and symptoms like malaise, fatigue, nausea, or abdominal pain may persist for weeks or months before presentation.
It is important to be able to differentiate uncomplicated from complicated UTIs. Remember to always consider the atypical presentations as well.
CEUFast, Inc. is committed to furthering diversity, equity, and inclusion (DEI). While reflecting on this course content, CEUFast, Inc. would like you to consider your individual perspective and question your own biases. Remember, implicit bias is a form of bias that impacts our practice as healthcare professionals. Implicit bias occurs when we have automatic prejudices, judgments, and/or a general attitude towards a person or a group of people based on associated stereotypes we have formed over time. These automatic thoughts occur without our conscious knowledge and without our intentional desire to discriminate. The concern with implicit bias is that this can impact our actions and decisions with our workplace leadership, colleagues, and even our patients. While it is our universal goal to treat everyone equally, our implicit biases can influence our interactions, assessments, communication, prioritization, and decision-making concerning patients, which can ultimately adversely impact health outcomes. It is important to keep this in mind in order to intentionally work to self-identify our own risk areas where our implicit biases might influence our behaviors. Together, we can cease perpetuating stereotypes and remind each other to remain mindful to help avoid reacting according to biases that are contrary to our conscious beliefs and values.