How are urinary tract infections treated?

Treating UTIs

1. Paediatric UTIs

Typically, oral fluids and antibiotics are the primary means of treatment for children affected by either uncomplicated or complicated UTIs.

Intravenously administered fluids and antibiotics will be given to children with severe or uroseptic conditions (sepsis that is localised to the urinary tract) in hospital. A child will also be hospitalised if he or she has signs of urinary obstruction, another underlying medical condition, is unable to tolerate medications or orally taken fluids, or is younger than 1 month old. Babies 2 months and younger with signs of kidney infection with also be hospitalised once diagnosed.

Infants (2 months and younger) displaying UTI symptoms with fever (due to bacterial causes)

In these cases hospital care will involve parenteral antibiotic therapy for complicated UTI and  kidney infection (pyelonephritis).

Antibiotics may be administered daily with dosages depending on an infant’s age. Monitoring of a child will take place daily until his or her fever has broken. Intravenous antibiotics will likely continue to be administered for between 24 and 36 hours once a fever has subsided, and the child begins to show improvement.

Oral antibiotics will not normally be prescribed to infants who are considered toxic (acutely or severely ill or who have complicated UTIs), display moderate to severe signs of dehydration, or who vomit persistently. Oral therapy is usually only an option for paediatric patients who are able to retain the medication, but this can be substituted with intravenously administered antibiotics if necessary.

An infant will normally be discharged from hospital within 48 to 72 hours and continue antibiotic therapy at home. Oral antibiotic therapy may be prescribed for between 10 and 14 days thereafter to clear the bacterial infection.

Antibiotics for home use will be selected with current drug resistance data in mind but should generally be able to effectively treat all known UTI pathogen organisms. Oral antibiotics may be prescribed for between 4 and 7 days, thereafter a follow-up doctor’s appointment will be recommended to assess the efficiency of treatment and whether the infection has cleared.

Bladder infections (cystitis) will typically be treated with a 4-day course of antibiotics. If no improvement is noted after 2 to 3 days of antibiotic treatment, a doctor may reassess a child’s condition and the antibiotic prescribed, selecting another which may be more beneficial.

Increase in fluid intake will also be recommended so as to encourage urine dilution and frequency of urination while on treatment. Treatment for bladder infections may also include of the administration of NSAIDs (non-steroidal anti-inflammatory drugs like Ibuprofen) and acetaminophen (Tylenol, Cetafen, Acephen or Mapap) to assist in alleviating symptoms of pain experienced with urination.

2. Adult UTIs – female

Treatment for adult women (non-pregnant patients)

Female patients who do not show signs of any urinary tract obstructions and do not have a recent history of catheterisation will generally be diagnosed with uncomplicated UTIs. Prescribed medication is typically the recommended means of treatment once a UTI has been diagnosed.

Antibiotics are aimed at clearing an infection, as well as preventing further infection complications (such as an infection of the kidneys). Medications (analgesics such as Phenazopyridine) to help alleviate any discomfort and pain associated with urination may also be recommended following a diagnosis for between 1 and 2 days. Drinking plenty of fluids will also be recommended to encourage dilution of urine flow.

Complicated infections are normally associated with underlying medical conditions, more persistent symptoms, kidney dysfunction, anatomic abnormalities (of the urinary tract), catheters, kidney transplant recipients or individuals with compromised immune systems. Complicated infections tend to be at higher risk of medication therapy failure. Symptoms tend to persist for at least 7 days in complicated cases.

Most of the recommended antibiotics are known to be effective against strains / species of E. coli, enterococci, Staphylococcus aureus, Klebsiella, Enterobacter, Proteus and Shigella pathogens. Ahead of prescribing any (oral) antibiotic options, a doctor will have assessed the current drug resistance patterns in the area of residence and recommend those which would be expected to be most effective at the time of diagnosis.

If a patient shows signs of rapid improvement within the first few days of treatment, dosages may be halted at around 7 days. Older female patients are also generally treated for a period of at least 7 days, especially if it is determined that an infection has occurred as a result of Staphylococcus saprophyticus microorganisms. Should treatment responses show slow or delayed improvements or if a woman is hospitalised with a complicated infection, treatment may be recommended over 10 to 14 days.

Treatment for pregnant adult women

Antibiotics will be recommended for pregnant women with either symptomatic or asymptomatic infections but will be selected with caution. A doctor will take into careful consideration the potential risks of complications as they apply to both the mother and unborn baby and all of these will be discussed ahead of treatment commencement, ensuring that the option with the best therapeutic outcome and safety profile is selected.

A doctor is likely to recommend longer courses of antibiotic treatment for pregnant women (although initial courses may be prescribed between 3 and 7 days), normally between 10 and 14 days to effectively achieve higher clearance rates of the infecting pathogen. A doctor may also recommend a urine culture within a week or two of antibiotic treatment commencement to assess the effectiveness of the selected drug and whether bacterial microorganisms are still present in the urine or not.

Treatment kidney infections in pregnant women

If a kidney infection is diagnosed during and initial consultation and testing procedures, a pregnant woman will likely be hospitalised for treatment. She will be given intravenously administered antibiotics and fluids to alleviate dehydration following bouts of nausea and vomiting. 

If a woman has a high fever, acetaminophen will usually be given to alleviate the symptom. Antiemetic medications that are safe for use in pregnancy can also be prescribed if a woman is struggling with nausea and vomiting (which can also occur as a side-effect of antibiotic treatment).

Treating physicians will keep a watchful eye on their pregnant patient during hospitalised treatment so as to avoid spontaneous miscarriage or preterm labour / delivery of an unborn baby while infections are being cleared with medications.

Surgical treatment of complicated UTI during pregnancy

It is rarely required but, in some instances, a surgical procedure may be required to treat a complicated UTI. Some instances that may warrant surgery include:

• Bladder diverticulum (often as a result of bladder obstructions or urethral scar tissue)
• Bladder stones
• Urethral syndrome (painful inflammation of the urethra)
• Lower urinary tract trauma
• Bladder cancer
• Interstitial cystitis (severe pain in the bladder)

If any procedures are required, it is generally recommended that they only be performed during a woman’s second trimester of pregnancy. Earlier surgical intervention may result in miscarriage. Intervention during the third trimester may induce preterm labour. If surgical procedures are required during the third trimester, these will typically be scheduled to coincide with the birth of a baby.

3. Adult UTIs – male

It is general practice to regard all male UTIs as complicated infections due to the fact that most infections occur in either infant or elderly males due to abnormalities of the urinary tract. ⁽¹⁴⁾ As such, treatment will be targeted to clear infections of both the lower and upper urinary tract. During diagnosis, the results of a urine culture may provide some drug adjustment consideration, especially if a known resistant organism is prevalent at the time of infection.

Senior males will be treated with particular caution, especially if a kidney infection is identified. Younger, sexually active males will be treated with both UTI symptoms and possible STD-associated factors.

Before treatment commences, males will be referred to a urologist if any of the following are identified:

• Anatomic abnormality
• Signs of an acute scrotum
• Indications of prostatitis (inflammation of the prostate)

Other pre-treatment consultations may be recommended in the following instances:

• If there are indications of unusual or resistant microorganisms. In this instance, a male patient will be referred to an infectious disease specialist.
• If a male patient has been using aminoglycosides for bacterial condition treatment already, he may be referred to a pharmacokinetics specialist for a consultation. This is to assess the possible risk of complications associated with the use of these medications which may include cranial nerve damage (which may result in hearing loss or vestibular dysfunction, such as dizziness or vertigo)
• In the case of non-bacterial prostatitis, a pain specialist may be consulted in order to assist in alleviating symptoms of discomfort.

Antibiotic treatment for male UTI and related conditions

As with females and children, antibiotic treatment is aimed at clearing infection, as well as reducing or preventing further complications.

Male patients who have comorbid conditions, urinary tract obstruction, compromised immune systems, symptoms of dehydration, rigor (body chills) or hyperpyrexia (extreme elevations in core body temperature), who cannot care for themselves at home (e.g. elderly patients) or who are unable to maintain hydration orally themselves may be hospitalised for treatment.

In hospital, patients will be treated with intravenously administered antibiotics (antimicrobial therapy). The selection of antibiotic therapy and dosages will be carefully recommended according to location of infection, type pf pathogen and associated conditions.

Antipyretic (fever reducing) and analgesic (pain relieving) medications, such as Phenazopyridine, along with intravenously administered fluids will also be given to ensure that an adequate flow of urine is encouraged. Antibiotic treatment for male UTI symptoms is generally recommended over a 10 to 14-day period.

Surgical procedures may be required to address issues such as obstructions. A bladder neck obstruction may be corrected with a transurethral incision of the bladder neck. If a part of the infected prostate gland requires removal, a partial transurethral proctectomy (TURP) may be recommended. An orchidopexy procedure can help to resolve torsions of the testicles and scrotum.

Along with antibiotic and pain relieving treatments, a doctor will highly recommend adequate hydration. He or she may also recommend an intake of foods and supplements that are rich in magnesium and phosphorus (these types of foods include dairy products, or dark green and leafy vegetables). A doctor will also encourage bedrest and the avoidance of physical activities such as bike riding for several weeks.

Sexual activity may resume when a patient and his partner have been cleared of infection with antibiotic treatment. Birth control methods, like use of condoms may be encouraged to reduce risk of potential infections in future.

Reference:

^{14. Cleveland Clinic. November 2013. Acute Uncomplicated Urinary Tract Infections: http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/infectious-disease/urinary-tract-infection/  [Accessed 28.03.2018]}