T h e Em e r g e n c y D e p a r t m e n t

D i a g n o s i s an d M a n a g e m e n t
o f U r i n a r y Tr a c t I n f e c t i o n
a, b
Brit Long, MD *, Alex Koyfman, MD

KEYWORDS
 Urinary tract infection  Cystitis  Pyelonephritis  Sepsis  Obstruction
 Hydronephrosis  Mimic

KEY POINTS
 The evaluation and management of urinary tract infections (UTIs) in the emergency depart-
ment depend on illness severity, patient hemodynamic status, and underlying comorbid-
ities. A variety of potentially deadly conditions may mimic cystitis or pyelonephritis.
 Dysuria, urinary frequency, and urinary urgency in the absence of vaginitis or cervicitis
with vaginal discharge are supportive of UTI.
 Most patients with simple cystitis and pyelonephritis can be treated as outpatients, and
the specific antibiotic used depends on the region’s antibiogram and diagnosis.
 Urinary testing with urinalysis or urine dipstick is associated with several pitfalls but can be
helpful when used appropriately. Urine cultures should be obtained in complicated or up-
per UTI. Simple and lower tract UTIs do not require urine cultures, unless the patient is
pregnant. Asymptomatic bacteriuria should only be treated in specific circumstances;
otherwise, it does not require antibiotics.

INTRODUCTION

Urinary tract infection (UTI) is a common condition evaluated and managed in the
emergency department (ED). Emergency physicians evaluate a wide spectrum of
UTIs, including uncomplicated cystitis, pyelonephritis, and even septic shock. When
compared with other hospital or outpatient settings, patients in the ED are often sicker.
Emergency physicians are faced with several challenges when managing patients with
UTI with limited history, absence of follow-up, lack of culture results, and less ability to
care for patients in a longitudinal manner. Patients in the ED may have little to no ability
to follow-up.

a
Department of Emergency Medicine, San Antonio Military Medical Center, 3841 Roger
Brooke Drive, Fort Sam Houston, TX 78234, USA; b Department of Emergency Medicine, The
University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX
75390, USA
* Corresponding author.
E-mail address: [email protected]

Emerg Med Clin N Am - (2018) -–-

https://doi.org/10.1016/j.emc.2018.06.003 emed.theclinics.com
0733-8627/18/Published by Elsevier Inc.
2 Long & Koyfman

Emergency physicians are tasked with several decisions. The first is determining if
an infection is complicated versus uncomplicated, second is assessing what labora-
tory and imaging evaluation is necessary, and third is determining the need for antibi-
otics and patient disposition.1–4 Potential mimics of UTI should also be considered.
This review addresses these factors through a focused evaluation of the literature.

DEFINITIONS

UTIs can be classified by location and the presence of functional or structural abnor-
malities. This classification is important, because evaluation and treatment depend on
accurate assessment. Infection of the bladder defines acute cystitis or lower tract UTI.
Pyelonephritis, which most commonly occurs when bacteria ascend to the kidney
from the bladder, is the most common presentation of upper UTI.1–5 Symptoms are
typically more severe, although it usually starts as simple cystitis.1–7 Untreated, pyelo-
nephritis has the potential in some cases to progress to septic shock and death.8,9
An uncomplicated UTI, or cystitis, occurs in young, healthy premenopausal
women.1,2,5,6 These women are not pregnant and do not possess structural or
functional urinary tract abnormalities.5–7 Uncomplicated infections of the lower urinary
tract are at low risk for treatment failure and are usually not associated with antibiotic-
resistant organisms, although resistance rates are continually increasing.6–8,10–14 All
other patients meet criteria for complicated infection, a heterogenous definition
(Box 1).8,15 Complicated infections are at risk for drug-resistant organisms and may
require further evaluation and more extensive treatment.3,4

Epidemiology
UTIs are a common disease: approximately half of women experience one infection
during their lifetime.1–3,16 Premenopausal women demonstrate an incidence of 0.5
to 0.7 cases per person-year in sexually active women.7,16 UTI risk factors for this pop-
ulation include sexual intercourse, spermicidal use, and prior UTI.1,2,6,7 Men demon-
strate lower rates of UTI, with 5 to 8 UTIs per 10,000 in young and middle-aged
men.17,18 Men older than 50 years, however, demonstrate a higher risk of UTI
(20%–50% prevalence) due to prostate enlargement, debilitation, and potential uri-
nary tract instrumentation.17–19 ED visits approached more than 3 million visits in
the United States in 2010, with more than 80% of visits made by women and 50%
in patients 18 years to 44 years old.2,3,20,21 Most of these patients are diagnosed

Box 1
Complicated urinary tract infection

 Pyelonephritis/upper UTI
 Male
 Pregnancy
 Anatomic abnormalities (vesicoureteral reflux, stricture, and neurogenic bladder)
 Urolithiasis
 Catheter, stent, or tube present in urinary system
 Malignancy, chemotherapy, and immunosuppression
 Failure of antibiotics
 Hospital/health care–associated UTI
 Emergency Medicine Evaluation and Management of Urinary Tract Infection 3

with simple acute cystitis, although pyelonephritis accounts for as much as 13% of
UTI ED evaluations.2,3,6 The annual incidence of pyelonephritis ranges from 459,000
to 1,138,000 patients in the United States.8,22 Patients presenting to the ED with
UTIs are typically sicker; in other settings, pyelonephritis accounts for 1 in 28 cystitis
cases.5,6 Pyelonephritis accounts for up to 4000 deaths in the United States
annually.5,8,23
The most common pathogen for UTI is Escherichia coli (more than 80%), followed
by Staphylococcus saprophyticus, with rates approaching 15%.1–5,24 Although these
two microbes cause a majority of uncomplicated and complicated UTIs, other gram-
negative bacilli, such as Klebsiella and Proteus mirabilis, and gram-positive bacteria,
such as enterococcus and group B streptococcus, can also result in UTI.25,26 Compli-
cated UTIs, including catheter-associated UTIs, can be caused by a larger range of
organisms and are often polymicrobial. Pseudomonas aeruginosa and Enterococcus
faecium, as well as extended-spectrum b-lactamase (ESBL)-producing bacteria,
more commonly result in complicated infection.2,3,7,25,26 Prevalence of resistance to
fluoroquinolones is increasing for uncomplicated and complicated pyelonephritis,
6.3% and 19.9%, respectively; and the prevalence of ESBL bacteria is also concern-
ing in uncomplicated and complicated pyelonephritis, 2.6% and 12.2%, respec-
tively.27 Infection due to S aureus is more likely due to bacteremic seeding of the
urogenital tract from another source.2,3 Other populations, such as young men and
women with vaginal discharge, pruritus, or other pelvic complaints, may be due to
sexually transmitted infection (STI) or uropathogenic E coli.4–7 Elderly men with history
of urinary obstruction have greater risk of polymicrobial infection and resistant
organisms.3,8,15,19

HISTORY AND EXAMINATION IN THE EMERGENCY DEPARTMENT

When a patient with concern or suspicion for UTI presents to the ED, several key ques-
tions should be asked. First, does the patient require resuscitation due to hemody-
namic instability from sepsis? Second, are the symptoms or presentation due to a
UTI, or is a mimic present? If it is a UTI, is it simple or complicated and lower or upper?
Is the patient pregnant, and could this be a STI? What antimicrobial should be used if it
is a UTI? Finally, what is the appropriate disposition?3
The type of UTI and location of infection often determine patient signs and symp-
toms, although history and examination are not 100% reliable in every patient.3,6,28,29
Patients with acute, uncomplicated cystitis typically experience dysuria, urinary fre-
quency, and urinary urgency.28,29 Although these are the classic findings in UTI,
they are by no means definitive for UTI. As discussed previously, these patients are
typically premenopausal nonpregnant women.1–5,28,29 Unfortunately, these symptoms
can also occur with STI, vaginitis, and chemical or allergic irritant exposure, although
UTI typically is not associated with vaginal discharge.3,6,7 No one specific history or
physical examination finding can rule in or rule out UTI. Specificity is 60% for fre-
quency, 78% to 88% for urgency, 52% to 58% for dysuria, and 69% to 91% for fe-
ver.28 Dysuria, frequency, and hematuria, however, increase the probability of
simple UTI.2,3,28,29 The absence of symptoms of vaginitis or cervicitis (vaginal
bleeding, discharge, and irritation) and presence of dysuria increase the likelihood
of UTI more than 90%, with positive likelihood ratio (LR) over 24.29 Importantly, self-
diagnosis of UTI carries a positive LR of 4.29
Differentiating lower tract UTI and upper tract UTI is predominantly clinical, based
on history and examination. Close evaluation of a patient’s hemodynamic status
may lead to clues of systemic toxicity and diagnosis of sepsis.3,5,6,8 Diagnosing
4 Long & Koyfman

pyelonephritis in a patient with fever, flank pain, and other urinary symptoms is
straightforward.8,28,29 Many patients with lower tract UTI, however, may also describe
vague back/flank pain or subjective fever. Patients with symptoms for more than
7 days, with history of recurrent UTI, or who have failed prior UTI therapy; men; and
patients with complicating factors (diabetes, immunosuppression, elderly, and preg-
nancy) require consideration of pyelonephritis and longer duration of treatment.3,8,30
If a patient fails a shorter course antibiotic therapy for simple cystitis, a diagnosis of
pyelonephritis requiring further treatment is recommended. Pyelonephritis often pre-
sents with fevers, chills, nausea/vomiting, and flank pain with lower tract symp-
toms.3,8,31 Patients may also describe pain in other regions, such as the abdomen,
and this is more common in patients who present atypically (elderly and immunocom-
promised). Fever is often present in pyelonephritis at some point in the disease
course.8,31 Up to 20% of patients with pyelonephritis, however, do not have urinary
symptoms, and clinical presentation and disease severity can vary significantly.32,33
Patients lacking fever more commonly have another condition, such as pelvic inflam-
matory disease (PID), diverticulitis, or cholecystitis.3 Elderly patients are more
commonly afebrile, are unable to describe symptoms, may present with pain in other
locations, and may demonstrate altered mental status or weakness. A genitourinary
examination should be considered in women with vaginal complaints (discharge)
and men with suspected UTI as well as close abdominal and back examination for po-
tential UTI mimics.

LABORATORY EVALUATION

Definitive diagnosis of UTI includes urine culture displaying significant numbers of

bacteria. However, urine cultures are not routinely performed in the ED. When urine
cultures are obtained, results are not readily available. In the ED, lower UTI is a clinical
diagnosis, and urinary testing may not be required if the patient meets criteria for un-
complicated cystitis.2–4 Urine testing can be helpful in specific situations, especially in
intermediate-risk patients.
Traditionally, urine is obtained for testing in the appropriate clinical setting. The
bladder and urine within the bladder are normally sterile. Several options are available
for urine collection: clean-catch midstream sample, suprapubic aspiration, and ure-
thral catheterization.2–4,34 The most common means is clean-catch midstream spec-
imen, although this may be difficult to obtain in pediatric and elderly patients.34–36 For
midstream collection, surrounding areas are typically appropriately cleansed.34–36
One study, however, found contamination rates were similar between those with
and without cleansing.37 Collection of midstream urine with or without cleansing pro-
duces a reasonable specimen. Catheterization may be required for ill or immobilized
patients. Once urine is collected, it should be analyzed as quickly as possible,
because a delay of more than 2 hours can result in unreliable results, and, if it cannot
be analyzed quickly, the specimen should be refrigerated.3,34–36
Urine cultures are usually not available at the time of ED evaluation, and other uri-
nary assessments can be used to assist in diagnosis, including urinary dipstick, micro-
scopic examination, and urine flow cytometry.2,3 The definition of UTI varies, however,
limiting routine use of several methods. Pyuria is the presence of whole or lysed white
blood cells (WBCs) in the urine and is one of the most reliable signs of UTI.38–40 An
abnormal result is greater than 10 WBCs/mm3 in an unspun voided midstream urine
sample, which occurs in approximately 96% of patients with UTI.38,40 A centrifuged
urinalysis demonstrating 2 WBCs/mm3 to 5 WBCs/mm3 or greater than or equal to
15 bacteria per high-power field (HPF) suggests UTI.39 WBC casts are evidence of
 Emergency Medicine Evaluation and Management of Urinary Tract Infection 5

pyelonephritis, and hematuria is also helpful, because hematuria is typically absent in

urethritis and vaginitis.40
The most prevalent means for diagnosing a UTI is by way of urine dipstick, as it is
inexpensive and convenient, and this test possesses sensitivity and specificity similar
to microscopic urinalysis.41,42 Dipsticks are reagent strips that can detect leukocyte
esterase (LE) and nitrite.40 LE reflects pyuria and is released by leukocytes, typically
in the setting of greater than 10 WBCs per HPF.40,43,44 To properly evaluate for
pyuria, the dipstick requires 30 seconds to 1 minute of urine contact. LE displays
sensitivity of 75% to 96% and specificity of 94% to 98% for UTI diagnosis.29,40,41,43
False-positive results occur with contaminated specimens, trichomonas infection,
and drugs or food that color urine red. False-negative results occur with intercurrent
or recent antibiotic therapy, glycosuria, proteinuria, high urine-specific gravity, and
low bacteria counts.40
Nitrites are evidence of the presence of Enterobacteriaceae, which convert urine ni-
trates to nitrite.40,44,45 A positive test is extremely specific but not sensitive.45,46 More
than 10,000 bacteria/mL urine are required to result in a positive nitrite test.40,45,46 Un-
fortunately, the nitrite dipstick reagent strip is sensitive to air. After 1 week of exposure
to air, up to one-third of strips provide a false-positive result, which increases to three-
fourths at 2 weeks.40,47 Nitrite testing possesses a sensitivity of 35% to 85% and
specificity of 95% for UTI diagnosis.44,48 Although specific, sensitivity is poor,
because S saprophyticus and enterococcus do not reduce nitrate to nitrite, and
certain drugs and food that result in red urine can also result in false-negative
tests.44,49 The test also requires time for urinary incubation within the bladder. The
combination of LE and nitrite results in a sensitivity of 75% to 90% and specificity
approaching 100%.48 Results of this test display several limitations. A history strongly
suggestive of UTI, even in the setting of negative LE and nitrite, may require treat-
ment.7,44 A positive LE or nitrite test without symptoms, however, does not necessarily
require antibiotics.44 Several pitfalls can exist in the interpretation of urine dipstick re-
sults (Table 1).
Urine cultures provide the definitive diagnosis of UTI, with greater than or equal to
105 colony-forming units (CFUs)/mL of bacteria or 102 CFUs/mL in the presence of
symptoms considered diagnostic.6,7,44 Urine cultures for uncomplicated cystitis
are not recommended.6,7 On a routine basis, urine cultures provide little diagnostic
utility in the ED. Pretreatment urine cultures in this patient population are not
cost effective, do not predict treatment outcomes, and do not affect patient
management.35,36,52,53 One prospective, double-blind, randomized placebo-
controlled trial evaluated women ages 16 years to 50 years with dysuria and fre-
quency but negative urine dipstick for LE and nitrites.36 Women receiving antibiotics
reported complete resolution of dysuria in 76% of patients compared with 26% of
the placebo arm. By day 7, more than 90% of women receiving antibiotics experi-
enced symptom resolution versus 59% in the placebo group.54 Patients not
improving with standard antimicrobial therapy, however, require urine culture. Urine
cultures are recommended for patients with complicated UTI, pyelonephritis, and
recent antimicrobial therapy.3,6,7
If urine cultures are obtained in the ED, a system should be in place for following re-
sults and ensuring that results are sent to the physician actively caring for a patient.3,6
If a culture result suggests resistance to the prescribed antibiotic, the patient should
be contacted. Patients with improved symptoms may not need a different antimicro-
bial. This is in part due to high urinary antibiotic concentrations, which may result in
clinical cure despite in vitro resistance. If symptoms have not improved, a different
treatment should be provided.
6 Long & Koyfman

Table 1
Pitfalls in urinary tract infection diagnosis using urine dipstick

Pitfall Explanation
Cloudy and smelly Odor and degree of transparency are not reliable in diagnosis
urine 5 UTI of UTI. Diet, urine crystals, hydration status, and other
factors affect urine appearance and smell.37,47–49
Squamous cells are SECs are poor markers of urine culture contamination.50,51 One
present 5 contamination study evaluated a quantitative threshold of SECs.50 In this
study, samples with fewer than 8 SECs/low-power field
demonstrated greater ability to predict bacteriuria on
urinalysis, but SECs did not accurately identify contaminated
urine.50
Positive LE or pyuria 5 UTI Positive LE demonstrates sensitivity 80%–90% and specificity
95%–98% for pyuria. WBC counts 6–10 cells/mL occur with
dehydration, oliguria, or anuria. Contamination, interstitial
nephritis, nephrolithiasis, tumor, interstitial cystitis,
intraabdominal pathology, and atypical organisms cause
pyuria.38,41,46
Positive nitrites in UA 5 UTI The test does have high specificity (95%) for gram-negative
bacteriuria, but it cannot be used alone and may be negative
with insufficient urine dwell time in the bladder or in
infection with organisms unable to convert nitrate to
nitrite.37,41,45,49

Abbreviations: LPF, low power field; UA, urinalysis; SEC, squamous epithelial cell.

Blood cultures are advised for only certain situations. They are not recommended
for uncomplicated cystitis.3,6,7 In pyelonephritis, blood cultures do not usually change
management, although bacteremia can be present in up to 40% of patients with py-
elonephritis.55–60 Blood and urine cultures are concordant in up to 97% of nonpreg-
nant adult women with simple pyelonephritis.58 In 1 study evaluating nonpregnant
patients with simple and complicated cases of pyelonephritis, 23% of patients had
positive blood cultures; of these, only 2 were discordant with urine culture results
and did not affect management.61 Several other studies suggest that blood culture re-
sults do not affect management in patients with pyelonephritis.55,62 Blood cultures are
most commonly positive in patients with severe illness, immunocompromised state,
those with urinary tract obstruction, and patients greater than 65 years old.8,58,63 In se-
vere sepsis or septic shock, blood cultures may be positive in up to 42% of patients,
with an odds ratio of 4.76 (95% CI, 1.43–15.84).60

IMAGING

Most patients with uncomplicated and complicated UTIs do not require imaging in an
ED, although no formal guidelines for imaging are present. Imaging may assist in pa-
tients where diagnostic uncertainty exists, those with toxic appearance and hemody-
namic instability, those with suspected urolithiasis with UTI, and those who have failed
therapy or have recurrent infection.3,8 In the setting of septic shock, imaging to further
determine the source of infection may be needed, because source control is a key
element in sepsis management.3,8,64 One recent study evaluated a clinical prediction
rule for use of radiologic imaging consisting of urine pH greater than 7.0, history of uro-
lithiasis, and/or renal insufficiency in patients with febrile UTI, which led to a reduction
in imaging tests by 40%.64 Imaging modalities include abdominal radiograph,
 Emergency Medicine Evaluation and Management of Urinary Tract Infection 7

ultrasound (US), and CT.64 Plain film radiography demonstrates lower sensitivity for
complication and is typically not used.3,6,65–68 A standard kidneys, ureter, and bladder
view has a sensitivity of 45% to 59% and specificity approaching 77% for detection of
renal pathology.65–69 US is a valuable examination in unstable patients who may not
tolerate CT. It is rapidly available, is not associated with radiation, and is cost-effec-
tive.68–72 It can demonstrate hydronephrosis, abscess, and hydroureter,71,73 with
sensitivity approaching 80% and specificity 73% for hydronephrosis.68–73 Evidence
of hydronephrosis on US in the setting of UTI requires further evaluation for obstruc-
tion.70–72 The most sensitive test for renal pathology is CT, however, which provides
information on the presence of anatomic complications (calculi), hydroureter, gas,
and abscess. If air is present on CT, emphysematous pyelonephritis should be consid-
ered, which is lethal.3,65,69 Renal artery or vein occlusion due to embolus or thrombus
requires IV contrast. Any concern for severe renal pathology or UTI mimic warrants im-
aging, often with CT.65,69,72–76

URINARY TRACT INFECTION MANAGEMENT

Treatment depends on patient comorbidities, diagnosis, and hemodynamic status.

Although up to 42% of infections may resolve on their own, antibiotics are typically
recommended.3,4,6,7 Antibiotic therapy must be individualized and selected based
on patient diagnosis, medication allergies, compliance history, cost, availability, and
local antibiograms (E coli and Klebsiella continue to demonstrate increasing resistance
to beta lactam antibiotics and fluoroquinolones) (Table 2).3,4,6,7,25,27 One of the most
important considerations is the institutional/regional antibiogram. If treating pyelone-
phritis, fosfomycin and nitrofurantoin are not recommended, because they concen-
trate in the bladder and not the kidneys.3,4,6,7 Fluoroquinolone resistance is
increasing,25,27,77,78 and in regions with greater than 10% resistance to fluoroquino-
lones, a long-acting parenteral cephalosporin is recommended in the ED.6,7 Resis-
tance to trimethoprim/sulfamethoxazole is also increasing.77,78 In areas of the
United States with high prevalence of ESBLs and severe sepsis or septic shock
with UTI, empiric treatment with a carbapenem is recommended.25,27,77,78 Ceftazi-
dime/avibactam and ceftolozane/tazobactam are two recently approved agents for
use in anticipated resistant Pseudomonas infection or carbapenem resistance.2 Pa-
tients with hemodynamic instability and concern for sepsis from UTI require intrave-
nous (IV) fluids and potentially vasopressors if the patient is unresponsive to IV
fluids.8,9,79 Evaluation for urinary obstruction in a patient with septic shock is neces-
sary, because close to 10% of patients with septic shock due to urinary source
have an associated obstruction, necessitating emergent urologic intervention.8,9,79
Source control is also vital in patients with sepsis from a urinary source. Hydroneph-
rosis and obstruction due to a urinary source require percutaneous or endourologic
drainage.3 Renal abscess may warrant drainage if a patient is unstable or if an abscess
is large enough. Emphysematous pyelonephritis, although rare, requires immediate
surgery for partial or total nephrectomy.3,4,80,81

CLINICAL MIMICS AND EMERGENCY DEPARTMENT APPROACH

Given the multitude of signs and symptoms associated with upper and lower UTIs,
maintaining a broad differential diagnosis is necessary. There are a significant number
of potentially dangerous mimics for lower UTIs and upper UTIs (Table 3). Nonemer-
gent diagnoses include bladder carcinoma, varicella zoster, bladder calculi, overac-
tive bladder, endometriosis, interstitial cystitis, pelvic congestion syndrome,
8 Long & Koyfman

Table 2
Antibiotic therapy for urinary tract infection

Diagnosis Antibiotic Dosing/Delivery Route Therapy Duration

Acute Nitrofurantoin 100 mg PO twice daily 5d
uncomplicated TMP/SMXa 1 DS tablet (160/800 mg) 3d
cystitis PO twice daily
Fosfomycin trometamol 3 g PO Once
Cefpodoxime 100 mg PO twice daily 3–7 d
Cephalexin 500 mg PO twice daily 3–7 d
Cefuroxime 250 mg PO twice daily 3–7 d
Acute Ciprofloxacina 500 mg PO twice daily 7d
complicated or 1000 mg XR once
cystitis daily
Levofloxacina 750 mg IV/PO once daily Once
TMP/SMX 1 DS tablet (160/800 mg) 5d
PO twice daily
Cefepime 2 g IV twice daily 3d
Ampicillin and Ampicillin, 1 g IV 4 Transition to PO
centamicin daily, and gentamicin, medication once
5–7 mg/kg/d IV able
Imipenem/cilastatin 500 mg IV 4 daily Transition to PO
(reserve for suspected medication once
ESBL) able
Pyelonephritis— TMP/SMXa 1 DS tablet (160/800 mg) 14 d
outpatient PO twice daily
Ciprofloxacina 500 mg PO twice daily 7d
or 1000 mg XR once
daily
Levofloxacina 750 mg PO once daily 5d
Cephalexin 500 mg PO 3 daily 10–14 d
Amoxicillin-clavulanate 875 mg/125 mg PO 3 10–14 d
daily
Cefixime 400 mg PO once daily 10–14 d
Cefpodoxime 200 mg PO twice daily 10–14 d
Pyelonephritis— Not suspecting enterococcus: Switch to PO
inpatient Ceftriaxone 1 g IV once daily therapy when
Ciprofloxacina 400 mg IV twice daily able
Levofloxacina 750 mg IV once daily
Cefepime 1 g IV 3 daily
Imipenem 500 mg IV 4 daily
Aztreonam 2 g IV 3 daily
Suspecting enterococcus:
Ampicillin and Ampicillin, 2 g IV 4
gentamicin daily, and gentamicin,
1 mg/kg IV 3 daily
Piperacillin/tazobactam 4.5 g IV 3 daily
Ampicillin/sulbactam 3 g IV 4 daily

Abbreviations: DS, double-strength; TMP/SMX, trimethoprim/sulfamethoxazole; XR, extended

release.
a
If local resistance to a fluoroquinolone is greater than 10%, then an initial IV dose of a long-
acting parenteral antimicrobial agent should be administered (1 g ceftriaxone or a 24-h consoli-
dated dose of an aminoglycoside). TMP/SMX should be avoided if local resistance greater than
20% or prescribed for UTI in the previous 3 mo. TMP/-SMX DS tablets may be utilized twice daily
for 14 d, however not in cases of enterococcal or pseudomonal infection.
Data from Refs.2–7
Table 3
Urinary tract infection mimics requiring emergency department intervention

Emergency Medicine Evaluation and Management of Urinary Tract Infection

Diagnosis Presentation/Evaluation Management
Abdominal aortic  Often asymptomatic until time of rupture.  Symptomatic or unstable patient: consult
aneurysm82  Insidious presentation, including weeks of progressive back pain (slow leak) vs vascular surgery and transfuse blood
sudden severe abdominal, flank, or back pain with or without hypotension or products.
syncope.  Emergent surgery for rupture: mortality
 Rare presentations: massive GI bleeding (aortoenteric fistula), hemorrhagic 34%–85%.
shock (rupture into the peritoneum), high-output heart failure (aortocaval  Stable patient: abdominal aorta >3 cm
fistula), or femoral neuropathy (secondary to aneurysmal rupture and requires referral and surveillance by US
enlarging hematoma). or CT every 6–12 mo. Consult vascular
 Risk factors: hypertension, smoking, male gender, white ethnicity, age >60, and surgery for aneurysms 5 cm; annual risk
disease occurring in a primary relative. of rupture 25%–40%.
 Symptomatic or clinically unstable patient: bedside US (95%–100% sensitive,
100% specific), type and cross.
 Stable patient: CT
Cholecystitis83,84  Patients often experience right upper quadrant or midepigastric pain and  Initiate antibiotic therapy:
nausea; may report fever and pain radiating to the flanks.  Mildly ill: ciprofloxacin, 400 mg IV, and
 Diagnosis is clinical: history, physical examination, and US findings. metronidazole, 500 mg IV.
 Risk factors: oral contraceptives or estrogen replacement therapy, diseases of  Critically ill: vancomycin, 20 mg/kg
the terminal ileum, cirrhosis, hemolytic diseases, pregnancy, obesity, and TPN. (up to 2 g) IV, and piperacillin/tazobactam,
 Physical examination findings: Murphy sign (positive LR: 2.8; 95% CI, 0.8–8.62). 4.5 g IV, or carbapenem.
 US (sensitivity 95%, specificity 98%): sonographic Murphy sign, pericholecystic  Consult general surgery.
fluid, gallstones/biliary sludge, gallbladder wall thickening >3 mm.  Diabetes is a risk factor for emphysematous
 Laboratory evaluation: CBC often demonstrates leukocytosis, and LFTs may be cholecystitis. If diagnosed, initiate antibiotic
elevated. therapy directed against gram-negative rods
and anaerobes, and consult surgery.

(continued on next page)

9
 10
Long & Koyfman
Table 3
(continued )
Diagnosis Presentation/Evaluation Management
Spinal epidural  Spinal epidural abscess may present with back pain in addition to fever,  Initiate broad-spectrum antibiotic therapy.
abscess85 myalgias, and focal neurologic deficit.  Consult neurosurgery for further treatment.
 Hematogenous spread of infection is most common (S aureus indicated in
60%–90% of cases).
 Frequently localized to the thoracic spine in adults (50%–80% of cases).
 Risk factors: spinal surgeries, lumbar punctures, trauma, advanced age,
pregnancy, sickle cell disease, IV drug abuse, diabetes, and immunosuppression.
 Laboratory studies: CBC (nonspecific, leukocytosis may be absent), ESR
(commonly elevated; may be falsely low in the setting of hyperglycemia,
systemic corticosteroid therapy, and high-dose aspirin therapy), CRP (frequently
elevated), and blood cultures.
 Imaging: MR imaging of the whole spine with and without contrast.
Urolithiasis86,87  Patients may report severe, waxing, and waning pain localized to the flanks or  Calculi 5 mm have a 70%–90% chance of
back with radiation to the abdomen, inguinal area, or groin. passing, those 5–10 mm <50% chance of passing.
 Risk factors: inflammatory bowel disease, bariatric surgery,  Patients without concomitant infection, signs of
hyperparathyroidism, renal tubular acidosis, gout, and diabetes. obstruction, or inherent renal pathology: consult
 History should include an inquiry regarding the aforementioned risk factors urology for follow-up. Discharge with medical
and medications related to stone formation. expulsive therapy (tamsulosin) of stones >5 mm,
 Physical examination: assess for signs of sepsis, which may indicate concomitant pain control, and antiemetic as needed.
infection.  Patients with renal calculi >5 mm, signs consistent
 Laboratory analysis: b-hCG for women, urinalysis, CBC (WBCs may be elevated), with obstruction, renal injury, concomitant
renal function (assess for renal injury). infection, or pregnant patients with calculi:
 Imaging: noncontrast helical CT is the gold standard (95%–100% sensitivity, consult urology.
94%–96% specificity). Consider US in pregnant women (19% sensitivity, limited  Initiate antibiotic therapy in the setting of
because only observational data, eg, hydronephrosis, may be obtained). infection.
Pneumonia88,89  Predominant clinical findings include cough, dyspnea, sputum production, and  Patients may be appropriate for discharge based
fever. May report flank pain (secondary to lower lobe pathology). on hemodynamic status, functional
 Common pathogens: S pneumoniae, nontypeable strains of Haemophilus status, and clinical scoring with antibiotics.
influenzae, and Moraxella catarrhalis; Mycoplasma pneumoniae frequent in  Clinically ill patients: initiate early goal-

Emergency Medicine Evaluation and Management of Urinary Tract Infection

adolescents and young adults. directed therapy: broad-spectrum antibiotics
 If recent dental procedures, seizures, alcoholism, or loss of consciousness, and fluid resuscitation and admit
suspect anaerobic pathogens.
 Risk factors: congestive heart failure, diabetes, alcoholism, COPD, and HIV.
 History: inquire as to IV antibiotic utilization in the previous 90 d (risk factor for
hospital acquired pneumonia).
 Physical examination: evaluate for evidence of sepsis and hemodynamic
instability.
 Laboratory evaluation: blood cultures for all patients who are clinically ill and in
whom a diagnosis of sepsis is suspected; serology ([Pneumocystis jirovecii, etc.]
or urine antigens [Legionella]) as appropriate.
 Imaging: chest radiograph; US may assist.
PE90  Patients with PE often present with dyspnea, tachypnea, and pleuritic chest  Anticoagulate as indicated.
pain, which may radiate to the flanks or abdomen.
 Temperature >38 C may be found.
 Evaluation: history and examination and risk-stratification.
 Bedside echocardiography may be used for rapid triage in the unstable patient
(evidence of right ventricular strain).
 ECG and chest radiography commonly nonspecific.
 Utilize D-dimer and PERC criteria as appropriate.
 Imaging: CT pulmonary angiography remains the gold standard for diagnosis.

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11
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Long & Koyfman
Table 3
(continued )
Diagnosis Presentation/Evaluation Management
Thromboembolic  Thromboembolic renovascular disease (renal artery thrombosis, renal vein  Consult vascular surgery.
renovascular thrombosis, or renal artery embolism) may present with flank pain.  Renal artery embolism or thrombosis:
disease91,92  Flank pain or pain radiating to the groin is present in 90% of patients with endovascular thrombolysis vs angioplasty
radiographically diagnosed renal artery embolism. or stenting.
 Renal vein thrombosis may be confused for pyelonephritis.  Renal vein thrombosis: systemic
 Risk factors for renal artery embolism: atrial fibrillation, cardiac thrombus after anticoagulation vs catheter-directed
infarction, atrial myxoma, endocarditis, and paradoxic emboli. thrombolytic therapy.
 Risk factors for renal artery thrombosis: renal artery atherosclerosis, renal artery  30-d mortality in patients presenting with renal
or aortic dissection, renal artery or aortic aneurysms, trauma, hypercoagulable artery embolism secondary to atrial fibrillation:
disorders, and malignancy. 10%–13%.
 Risk factor for renal vein thrombosis: nephrotic syndrome.
 Men with renal vein thrombosis may present with left-sided hydrocele. Patients
with renal artery embolism or thrombosis may demonstrate hypertensive
emergency.
 Laboratory evaluation: renal vein thrombosis may have leukocytosis. Renal
artery or vein pathology may have variable renal function. Acute kidney injury
to acute renal failure.
 Urinalysis: hematuria in up to 72% of cases of renal artery embolism.
 Imaging: CT angiogram for renal artery thrombus, with venography for renal
vein thrombus.
Appendicitis93,94  Lifetime risk of appendicitis is 8.6% in men and 6.7% in women.  Fluid resuscitation, IV antibiotics, and
 50%–60% of adolescent and adult patients with appendicitis report surgical consultation.
periumbilical pain migrating to the right lower quadrant. This presentation is
rare in elderly patients (15%–30%).
 Patients with signs/symptoms suggestive of peritonitis: immediate surgical
consult.
 Laboratory studies: leukocytosis and elevated acute-phase inflammatory
markers common but not definitive.
 Imaging: IV contrast CT considered the imaging study of choice (94% sensitivity,
95% specificity). US (86% sensitivity and 81% specificity) and MR imaging
(pediatric patients, pregnant women) may be used for definitive diagnosis.
Diverticulitis95,96  Diverticulitis and diverticular abscess may present with lower quadrant pain  Uncomplicated diverticulitis: patients who are PO
associated with fever, nausea, emesis, and diarrhea. tolerant may be discharged home with antibiotic
 Laboratory evaluation: CBC (leukocytosis common), UA may have sterile pyuria. therapy. Failure to respond to outpatient therapy
 Imaging: systemically ill patient with concern for complicated diverticulitis within 48–72 h: consider repeat investigation for

Emergency Medicine Evaluation and Management of Urinary Tract Infection

(requiring surgical evaluation and management) or those who are alternative diagnoses or surgical consultation.
immunosuppressed, have numerous medical comorbidities or are elderly: CT  Complicated diverticulitis: fluid resuscitation,
with IV contrast approaches 100% sensitivity. parenteral antibiotic therapy, and surgical
 Uncomplicated diverticulitis: patients with a history of diverticular disease or consultation with consideration for interventional
diverticulitis who are not systemically ill may not require imaging. radiology if localized abscess.
Ectopic  Currently accounts for 2% of pregnancies in the United States.  Emergent obstetric consultation for all patients
pregnancy97  Suspect in women of childbearing age presenting with amenorrhea and with an identified ectopic pregnancy.
abdominal pain, with or without vaginal bleeding.  Patients with US absent findings: obstetric
 Signs of rupture and subsequent hemorrhage: hypotension with or without follow-up in 1–7 d with repeat serum b-hCG
syncope. and repeat US; considered an ectopic pregnancy
 Risk factors: PID, endometriosis, infertility treatments, previous tubal until proved otherwise.
procedures, previous ectopic pregnancy, and multiple sexual partners.  Rhesus factor negative patients experiencing
 Physical examination: pelvic examination to assess cervical os. Bimanual bleeding during pregnancy require RhoGAM
examination reveals adnexal tenderness or mass in 50% of cases. administration.
 Laboratory evaluation: serum b-hCG level, perform CBC with type and screen or
type and cross as appropriate.
 Imaging: transvaginal US. US expected to demonstrates signs consistent with
pregnancy (gestational sac and yolk sac) at serum b-hCG levels >2000 mIU/mL.
Epididymitis/  Patients frequently report pain and swelling of the scrotum. Pain frequently  Epididymitis: initiate antibiotic therapy as
orchitis98,99 radiates to the groin and suprapubic area. appropriate. Complications: testicular
 Epididymitis may occur secondary to bacterial infection (Pseudomonas or infarction, abscess, or pyocele of the scrotum.
coliform species in men >age 35), STI, or rarely with trauma. Mumps: spread of  Orchitis: bacterial orchitis should receive
hematogenous infection or viral infection (mumps in 20%). Pyogenic form may antibiotic therapy. Viral orchitis resolves in
occur due to E coli, Klebsiella, P aeruginosa, staphylococci, or streptococci. 4–5 d (mild cases) to 3 wk (severe cases).
 Physical examination: tenderness with palpation of the posterior aspect of the
scrotum. Hydrocele may occur secondary to secretion of inflammatory fluid
between the layers of the tunica vaginalis. Orchitis often presents with
unilateral pain, though pyogenic causes associated with systemic illness.
 Laboratory evaluation: UA and STI laboratory tests.
 Imaging: color-flow Doppler US useful for the differential diagnosis of
complicated cases.

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13
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Long & Koyfman
Table 3
(continued )
Diagnosis Presentation/Evaluation Management
Ovarian  Women with ovarian torsion present with severe lower abdominal pain with or  Surgical emergency: consult gynecology as soon
torsion100,101 without nausea and emesis. as the diagnosis is suspected.
 Risk factors: infertility therapy, pregnancy, and history of ovarian cysts.
 Physical examination: 50%–90% of patients display a tender adnexal mass or
adnexal fullness on examination.
 Imaging: transvaginal US should be used for evaluation. The most consistent
finding indicating torsion is a unilaterally enlarged ovary; however, up to 50%
of patients may have a normal US. The presence or absence of arterial and
venous Doppler flow does not exclude the diagnosis.
Testicular  Sudden onset of testicular pain without fever or urinary symptoms. Pain may  Consult urology.
torsion102 radiate to the groin or suprapubic region.  Perform manual detorsion (external rotation
 Intravaginal torsion (malrotation of the spermatic cord within the tunica of testis toward the thigh) without delay if
vaginalis) occurs in 90% of cases. clinical diagnosis apparent.
 Physical examination may include a firm, high-riding testis with horizontal lie,  80% testicular salvage if detorsion occurs
and absent cremasteric reflex. within 6–12 h of onset.
 Imaging: US may demonstrate absent/decreased testicular blood flow.
 PID103,104  Most common cause of female infertility and ectopic pregnancy, with peak  Initiate empiric antibiotic treatment in sexually
incidence 15–24 y. active young women with cervical motion
 Patients often report lower abdominal pain, nausea, emesis, fever, urinary tenderness or uterine/adnexal tenderness.
symptoms, and vaginal discharge.  Patients frequently require parenteral

Emergency Medicine Evaluation and Management of Urinary Tract Infection

 Risk factors: douching, multiple sexual partners, IUD use, history of PID (20% antibiotic therapy (estimated 25,000 patients
recurrence rate), and chlamydial or gonococcal cervicitis (8%–10% develop hospitalized annually).
PID).
 Physical examination: cervical motion tenderness, adnexal tenderness, with or
without cervical discharge. Patients with perihepatitis may present with right
upper quadrant pain.
 Laboratory studies: CBC (often demonstrates leukocytosis), UA, ESR/CRP (may
be elevated), and STI testing.
 Imaging: transvaginal US useful for assessing the presence of PID complications.
TOA104,105  Lower abdominal pain, high fever, and nausea are the hallmarks of TOAs and  Parenteral IV antibiotic therapy is indicated in
salpingitis. patients with suspected salpingitis/TOA and
 A majority of TOAs result from gonococcal and chlamydial infections. should be continued until the patient is
 Risk factors: history of STIs and multiple sexual partners. asymptomatic, has been afebrile for 24–48 h,
 Laboratory evaluation: cervical samples for gonorrhea and chlamydia testing, and resolution of leukocytosis.
CBC (leukocytosis commonly >20,000/mm3).
 Imaging: US or CT with IV contrast are both highly sensitive for the diagnosis of
TOA.

Abbreviations: CBC, complete blood cell count; COPD, chronic obstructive pulmonary disease; ESR, erythrocyte sedimentation rate; GI, gastrointestinal; hCG, hu-
man chorionic gonadotropin; LFT, liver function test; PE, pulmonary embolism; PERC, Pulmonary Embolism Rule-out Criteria; TOA, tubo-ovarian abscess; TPN, total
parenteral nutrition; UA, urinalysis.

15
16 Long & Koyfman

nonvenereal vulvovaginitis, prostadynia, and vulvodynia, which are not further

explored in this article. These conditions may be managed in the outpatient setting.

SPECIAL POPULATIONS

Other important aspects in the evaluation and management of patients with sus-
pected UTI include those with urolithiasis and potential UTI, noninfectious dysuria,
sterile pyuria, and those with asymptomatic bacteriuria (ASB). These patients can
produce a quandary, because overtreatment for suspected UTI can result in
adverse medication events and increased antibiotic resistance. Careful consider-
ation of the patient and symptoms is required, rather than relying solely on labora-
tory assessment.

Urolithiasis and Urinary Tract Infection

Patients with urolithiasis often present to the ED in severe pain.86,87 UTI can compli-
cate this condition and may result in significant morbidity and mortality if not
adequately treated, with up to 8% of patients with urolithiasis experiencing UTI.106
In the setting of urolithiasis, UTI is more commonly associated with Pseudomonas
or Proteus.3,107 Diagnosis of UTI can be difficult in these patients. The UA is not always
easily interpreted in urolithiasis, which can produce pyuria and hematuria.86,87 Female
gender, dysuria, frequency, chills, prior UTI, and fever are associated with UTI in the
setting of urolithiasis.106 As many as half of patients, however, may not have a fever.
Pyuria with greater than or equal to 5 WBCs per HPF demonstrates 86% sensitivity
and 79% specificity for UTI and, as pyuria increases, the risk of infection increases.106
One study of patients with pyonephrosis associated with nephrolithiasis suggested a
wide spectrum of clinical presentations, ranging from ASB to severe sepsis, from
UTI.108 If UTI is suspected in the setting of urolithiasis, antimicrobials are likely indi-
cated in conjunction with urology consultation.3 Obstruction can be life-threatening,
warranting emergent intervention for source control.79 UTI with nonobstructing stones
can be treated with outpatient antimicrobials and follow-up.106,107,109,110

Noninfectious Dysuria
Dysuria without evidence of UTI on UA can be challenging. Self-diagnosis of UTI
demonstrates a positive LR of 4 for UTI, whereas the presence of urinary symptoms
and absence of symptoms associated with vaginitis possesses a positive LR of 24 in
reproductive-aged women.29 Other patient populations, however, can be difficult.
Etiologies of noninfectious dysuria include atrophic vaginitis, urethral trauma, or
reaction to hygiene products.2–4,6 In men, benign prostatic hypertrophy can result
in urethral obstruction, dysuria, and frequency, whereas urethral strictures from
STI, urethral instrumentation, cancer, physical activity, or calculi may also result in
dysuria.2,3

Sterile Pyuria
Urinalysis with WBCs and no bacteria defines sterile pyuria.29,40 This finding pos-
sesses a wide differential with a variety of conditions.111–115 One series of patients
with appendicitis found one-third had urinary symptoms with sterile pyuria, likely
due to appendiceal inflammation affecting the ureter.111,112 STI, diverticulitis, peri-
nephric abscess, renal tuberculosis or papillary necrosis, polycystic kidney disease,
nephropathy, and nephritis may result in pyuria.3,40,113–115 Patients with UTI typically
demonstrate bacteriuria with pyuria in the setting of urinary symptoms.44
 Emergency Medicine Evaluation and Management of Urinary Tract Infection 17

Urinary Tract Infection and Sexually Transmitted Infection

Differentiating UTI and STI can be difficult, as these conditions are common in
reproductive-aged healthy patients.2–4 A genitourinary examination may be needed
for further differentiation and specimen collection. One cross-sectional study of
sexually active women found a prevalence of 17% for UTI, 33% for STI, and 4%
for both.116 Urinary symptoms in this population did not predict STI.116 Another
study, however, found an incidence of 9% for STI compared with 57% for UTI.117
UTI and STI can overlap with symptoms, including dysuria, although UTI is typically
not associated with vaginal discharge as with STI.3,28,29 STI typically presents with
more gradual onset of symptoms, vaginal discharge/bleeding, lower abdominal
pain, pruritis, dyspareunia, external dysuria, new sexual partner, and no change in
frequency or urgency.118 Chlamydia trachomatis and Neisseria gonorrhoeae are
the most common causes of cervicitis or PID in women and epididymitis or prosta-
titis in reproductive-aged men.3,103–105 Unfortunately, point-of-care testing for iden-
tification of these organisms is not available in all EDs, although several tests
demonstrate promise.119,120 Clinicians may treat empirically for UTI or STI or treat
for both concurrently.3 If the clinician decides to treat only one, follow-up must be
in place to evaluate for continued symptoms and assessment of testing completed
in the ED.

Asymptomatic Bacteriuria
Bacteria in the urine without symptoms of UTI defines ASB, specifically in women with
2 consecutive clean-catch voided specimens with the same organism in greater
than 105 CFUs/mL and in men with 1 specimen and the same organism count.121–123
This finding does not definitively diagnose UTI, and ASB rates increase with
age.40,44,121,124,125 One study found 5% of sexually active young women demonstrate
ASB.123 Rates of ASB approach 25% to 50% of women and 15% to 49% of men
without indwelling catheters.124 These rates increase in the elderly due to altered elim-
ination, anatomic variations of the urogenital tract, poor hygiene, hormonal changes,
and neurologic impairment.121,125 Many of these organisms are not harmful but rather
commensal organisms.44 A symptomatic UTI in the elderly patient is less common
than ASB,125 and ASB is not associated with long-term adverse outcomes, such as
pyelonephritis, sepsis, or renal failure.126 ASB has not been shown to increase the
risk of hypertension, kidney disease, or death in patients with otherwise normal im-
mune status.127 Renal transplant patients, however, are at higher risk of pyelonephritis
with ASB.128,129 Bacteria obtained from urine culture is also not definitive for diagnosis
of UTI.7,44
Clinical signs and symptoms of UTI are needed for treatment, but many patients are
not able to provide these.44,121 Emergency physicians regularly evaluate older patients
unable to provide history and examination. A 2014 study recommended treatment if
patients demonstrated bacteriuria and pyuria with two of the following: fever, wors-
ening urinary frequency or urgency, acute dysuria, suprapubic tenderness,
and costovertebral angle tenderness.130 Other possible formulas to differentiate
UTI and bacteriuria are the following: pyuria 1 bacteriuria 1 nitrites 5 infection; bacte-
riuria but no pyuria 5 colonization/bacteriuria; and pyuria alone but no
bacteria 5 inflammation.131 Patients undergoing instrumentation or surgery of the
bladder may require antibiotics.3,39 ASB in pregnancy also requires treatment with an-
tibiotics to decrease the risk of maternal-fetal morbidity and pyelonephritis.132,133
Treating patients without true UTI can increase antimicrobial resistance as well as
expose patients to dangerous side effects and diseases, such as Clostridium difficile
18 Long & Koyfman

colitis.121,134–136 Antibiotics are used inappropriately in close to half of patients with

ASB.136 Educational programs and knowledge of ASB, however, can effectively
reduce inappropriate treatment.136

What About the Older Patient with Altered Mental Status or Recurrent Falls?
Altered mental status, “failure to thrive,” or recurrent falls in an elderly patient encom-
pass a large differential. History and examination are often unrevealing, resulting in
further testing, often with urinalysis. If UTI is a contributor, systemic signs or symp-
toms should be present, along with evidence of UTI, such as dysuria.44,134 In patients
with clinical suspicion of UTI without a catheter, acute change in mental status is asso-
ciated with bacteriuria and pyuria.135 Several studies suggest that urinary testing in a
patient with a history of falls but no signs or symptoms of UTI is unlikely to yield evi-
dence of pyuria or bacteriuria.44,136–140
Patients with chronic dementia and recurrent falls or those who are altered and un-
able to provide a history of urinary symptoms can be challenging. Evaluation for supra-
pubic or CVA tenderness in conjunction with UA can be helpful.44 UA with positive
nitrites, pyuria, and bacteriuria may be suggestive of UTI.44,141 In patients for whom
history and examination are unreliable but with no other explanation for AMS, one
study recommends using bacteriuria with other markers of systemic inflammation,
including fever/hypothermia, elevated WBC/C-reactive protein (CRP), elevated blood
glucose in absence of diabetes, and acutely altered mental status to diagnose UTI and
begin treatment.141 If urine dipstick demonstrates negative LE and nitrite, then UTI is
not present.3,44,141 Other causes of altered mental status must be excluded before
diagnosing UTI as the sole cause of altered mental status. If a patient meets criteria
for sepsis or has elevated markers of inflammation and the UA is consistent with
UTI, then treatment is warranted.3,4,8,44

DISPOSITION

Patient disposition is a key component of every patient evaluation in the ED. No vali-
dated decision rule is available for patients with UTI, unlike pneumonia. The majority of
patients with uncomplicated and even complicated UTIs are appropriate for
discharge.2–7 Possible reasons for admission are discussed in Box 2. Patients with py-
elonephritis are more likely to warrant admission due to fever, vomiting, and tachy-
cardia, but those who improve after IV fluids, antibiotics, and antiemetics can
potentially be discharged with close follow-up.3,7,8 Patients without any of the findings
listed in Box 2 are otherwise appropriate for discharge.

Box 2
Indications for admission

Inability to tolerate oral intake with severe nausea and vomiting

Hemodynamic instability
Obstruction or complication along urinary tract
Failure of outpatient therapy, including antibiotics
Poor social support, inability to obtain medications, and unable to attend follow-up
Concern for resistant organism with no option for oral antibiotic therapy
Pregnancy with pyelonephritis
 Emergency Medicine Evaluation and Management of Urinary Tract Infection 19

For patients discharged with an oral antibiotic, follow-up is recommended to ensure

the patient is improving.2–7 If a urine culture is obtained, a follow-up process should be
in place to ensure that antibiotic treatment was adequate. A patient who is not
improving or is worsening after 1-2 days of antibiotics requires reevaluation with
further testing. Imaging to evaluate for a UTI mimic, complicated UTI, or obstruction
may be needed as well as urine culture.

SUMMARY

UTI presents along a wide spectrum, commonly evaluated and managed in the ED.
No single history or examination finding is definitive for diagnosis, but dysuria, uri-
nary frequency, and urinary urgency in the absence of vaginal discharge strongly
suggest UTI. History and examination should be used in combination with urine
testing for diagnosis. Imaging is often not needed, except in specific circum-
stances. Most patients with simple cystitis and pyelonephritis can be treated
as outpatients, and prescribed antibiotic depends on the region’s antibiogram
and diagnosis. A variety of potentially dangerous conditions can mimic UTI and
pyelonephritis.

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