Genitourinary Infection

Asymptomatic Bacteriuria

>100k CFU bacteria in appropriately collected urine specimen without symptoms/signs of UTI. Bacteriuria, foul odor, urine appearance, pyuria, falls and/or confusion alone are not indicative of infection.
Oliguric ESRD pts and all urinary retention patients may have bacteriuria from colonization due to lack of flushing of bladder
Tx only required for specific populations: Pregnant women (screening performed at 12 – 16W), anticipated urologic intervention, renal transplant (within 30d of transplant)

Clinical symptoms of UTI (dysuria, urgency, frequency, hematuria WITHOUT systemic Sxs like fever, hypotension, etc.) in non-pregnant, immunocompetent, neurologically intact pt with normal urologic anatomy and no indwelling urinary catheters

Empiric Tx

Infection beyond the bladder in women or men: pyelo, febrile or bacteremic UTI, catheterassociated (CAUTI), or prostatitis. Fever, pyuria, and CVA tenderness suggest pyelo.
Consider a complicated UTI if any of the following are present:
- Renal calculi or other obstructive disease, immunosuppressed host, abnormal urological anatomy (including stents), presence of a urinary catheter, sepsis or bacteremia

Mid-stream or catheter-obtained UA with reflex UCx
If unable to obtain history, evaluate objective signs of infection (fever, hypotension, tachycardia, leukocytosis, etc.)
If no pyuria, consider alternative diagnoses or proximal ureteral obstruction
- Pyuria is common in the presence of a urinary catheter, kidney stones, urostomy, ileal conduit and other invasive devices, and may not indicate infection
All febrile or septic patient who fail to respond to appropriate broad-spectrum abx within 48-72 hours should undergo imaging (renal US or CT AP with contrast) to exclude complications (abscess, retention, calculi, gas, obstruction)

Vandy ASP Website for UTI
If UCx w/in last 6M, use that organism to guide abx
Empiric: CTX, alternatively Pip-tazo or cefe if PsA risk factors
Oral Step Down Treatment:
- W/o bacteremia, pyelo, MDR: Cephalexin, Amox-clav, amox, TMP-SMX, levofloxacin, cipro
- Duration depends on how many days of IV abx precede change to PO
- With bacteremia and pyelo: Tailor to organism with duration per VUMC ASP Uncomplicated Oral Options for Uncomplicated Bacteremia
See IDSA guidelines: IDSA 2025 Guideline Update on Complicated Urinary Tract Infections

Cx w/ > 103 cfu/mL of uropathogenic bacteria + signs or symptoms c/w infection + indwelling urethral/suprapubic catheter or intermittent catheterization.
Duration = greatest risk factor (increases 3-10% per day of catheterization). Other risks: female, DM, elderly, colonization of catheter bag, poor care
Bacteriuria, foul odor, pyuria, urine appearance falls and/or confusion alone are not indicative of infection in pts who are otherwise asymptomatic.
Ensure clean sample collected: Catheter is removed and midstream sample obtained
- If catheterization required; removal of old catheter and sample taken from new catheter

Distinguish uncomplicated vs complicated UTI (see above)
Special note regarding Candida UTI management: Candida is generally not pathogenic
- Presence in urine does not indicate infection (unless perinephric abscess, renal transplant, or complex fistulous disease)
- Fluconazole achieves excellent urinary penetration while micafungin, ampho do not
- If fluconazole-resistant Candida is cultured or suspected, consult ID
- Susceptibilities are not routinely run-on Candida from UCx and need to be requested
Catheter management
- Should be replaced after 24-48 hrs of abx (preferably permanently removed).
- If catheterization is necessary, intermittent catheterization preferred over continuous use with pt educations on cleaning/hygiene prior to catheterization. Condom catheters and pure wicks also preferred over foley catheter