Complicated Urinary Tract Infection ( UTI ) || #aetcm || #emergency medicine ||

Added: 2026-06-04

[00:00:06]Welcome to ATCM, the emergency medicine channel. Shall I start, sir?

[00:00:11]A 35-year-old female came to the ER with complaints of fever for 2 days, burning sensation while urination for the 3 days, and increased frequency and urge urination of urination for the past 3 days, and lower abdominal pain for the past 2 days.

[00:00:26]On initial assessment, the patient was conscious, oriented, and obeying commands.

[00:00:30]Uh airway was patent with no hoarseness, stridors, or secretions. Breathing respiratory rate was 20 per minute with saturation 99% in room air.

[00:00:39]Circulation-wise, pulse rate was 100 per minute with BP 110/80. CRT was less than 2 seconds, and all peripheral pulses were felt equally.

[00:00:49]Disability-wise, GCS was 15 out of 15 15, and pupils were equally reactive.

[00:00:54]Exposure-wise, temperature was around 100° F with the GRBS 100 mg/dL.

[00:01:00]Adjuncts to primary survey, we have done an VBG, CBC, CRP point of care. In that, total count was 15,000 with CRP of 60, and HP was 13 with neutrophil 82% and lymphocyte 14%. Neutrophilic leukocytosis.

[00:01:17]Then, in VBG-wise, we got a pH of 7.40 with a bicarb 23, sodium was 138, potassium was 4.1 with lactate 1.5.

[00:01:29]Sample history, a 35-year-old female with no known comorbs, came to the ER with complaints of burning sensation while urination associated with increased frequency of urination.

[00:01:39]This was also associated with lower abdominal pain, mainly over the suprapubic region, and fever with chills for the past 2 days.

[00:01:47]No history of any hematuria, vomiting, nausea, no history of any flank pains, vaginal discharge, or any recent hospital uh recent catheterization or uh histories.

[00:01:59]Past history, patient has no comops, no history of any recurring UTI episodes or anything. No previous similar history she doesn't have. Personal uh history, she's having a mixed diet with normal bowel and bladder habits.

[00:02:13]General examination wise, the patient was conscious oriented with temperature 100° F.

[00:02:18]Systemic examination, abdomen was soft but there was suprapubic tenderness present.

[00:02:23]Uh we uh we have done an USG abdomen. Uh it shows features suggestive of cystitis. There was no hydroureteronephritis or any renal calculi.

[00:02:34]Urine routine was done, which shows a pus cells of 30 to 40 with a bacteria 3+.

[00:02:41]>> What are the reasons for pus cells in urine?

[00:02:44]>> Epithelial shed down.

[00:02:45]>> Epithelial shedding is the most common thing, especially in elderly female patients.

[00:02:50]>> female patients.

[00:02:51]>> No.

[00:02:51]Other than that?

[00:02:52]>> No.

[00:02:56]Urine extreme.

[00:02:57]>> Infection, bacteria, virus, fungus, including tuberculosis.

[00:03:03]Okay.

[00:03:04]Then, anything else?

[00:03:06]>> Kidney stone, calculi.

[00:03:07]>> Calculi. Okay. Stones. They also can produce some sort of pus cells. Okay.

[00:03:14]>> So we have made a diagnosis of acute bacterial UTI.

[00:03:18]>> How do you make a diagnosis of bacterial UTI?

[00:03:20]>> Because uh lympho- neutrophils were predominant.

[00:03:23]>> Neutrophils are elevated.

[00:03:25]>> Uh it's complicated because she's having fever.

[00:03:28]>> Mhm.

[00:03:29]>> Uh currently to the guidelines of IDSA >> They are saying if fever is there, it will be complicated.

[00:03:35]>> UTI. And she was later admitted under general medicine for further uh management.

[00:03:42]Uh from our side we have given for temperature control we have given injection paracetamol 1 g IV stat.

[00:03:48]>> [snorts] >> Then we have started on patient on ceftriaxone 1 g uh was given as a >> What else you do for this patient it is not a must in emergency room what else you must do before starting antibiotic?

[00:04:00]>> Blood cultures and urine cultures.

[00:04:04]>> Blood culture may not be apt in this patient you may not get anything if only in sepsis you will get that. Urine culture should be sent.

[00:04:11]What what what type of urine culture it is?

[00:04:15]Is a normal taken urine or something else?

[00:04:18]>> Midstream.

[00:04:19]>> Midstream okay. What else you can do other than urine culture?

[00:04:25]Huh?

[00:04:25]Culture and sensitivity okay that is a single test then procalcitonin What is the importance of procalcitonin?

[00:04:35]>> Infection and it will be elevated >> Procalcitonin is an inflammatory marker of bacterial infection but normally urinary tract infection if it is a local infection it may be less than two normally is one less than two but if it the patient is going for a systemic infection sepsis it will be high it will be four five six and if it is sepsis it may be 50 60 like that okay so that is a very useful investigation.

[00:05:03]What else?

[00:05:04]So you have sent a urine culture you have sent a probably procalcitonin then ultrasound is done >> Ultrasound has been done.

[00:05:16]>> What are other investigations you routinely ask in UTI?

[00:05:22]Creatinine Creatinine is very important because many of the urinary tract infection will produce ascending type of infection in pyelonephritis. They will have more symptoms than simple UTI okay abdominal pain tenderness chills rigors very high count so pyelonephritis to be ruled out ultrasound may not be sufficient you may have to go for CT so creatinine is a must. What was the creatinine?

[00:05:49]>> Uh here patient's uh creatinine was only 0.8.

[00:05:52]>> 0.8, so it doesn't uh go in favor of a pyelonephritis.

[00:05:57]Okay.

[00:05:58]>> Uh then uh uh According to the IDSA guidelines, we can give antibiotics uh cephalexin first generation can be given. Then ceftriaxone or fluoroquinolones can also be given. Red flag signs in UTIs, patient going in hypotension.

[00:06:16]>> Okay.

[00:06:16]>> Then uh altered sensorium, then increased creatinine level, and USG there is hydronephrosis or pyelonephritis features.

[00:06:25]Treatment of normal UTI, we mainly give first-line treatment as fluoroquinolones can be given. Uh >> Where do you avoid fluoroquinolones?

[00:06:34]Which all >> Seizure patients.

[00:06:35]>> Seizure patients, elderly individuals.

[00:06:37]>> Uh elderly.

[00:06:38]Then in case of a patient who are admitted, we can give ceftriaxone as because it covers both gram-negative and some gram-positive also.

[00:06:48]>> UTIs classically produced by gram-negative or Mostly by gram-negative. Very rarely gram-positive will come in urine, but it can happen. Gram-negative is predominant. In that, E. coli is most common.

[00:07:00]So, ceftriaxone is enough for most of the UTIs.

[00:07:04]>> Uh then in case of uncomplicated UTI, we can give oral antibiotics which given for about 3 to 5 days. Course can be given.

[00:07:13]>> What same?

[00:07:14]>> Uh >> Fluoroquinolones.

[00:07:16]>> Fluoroquinolones can be given.

[00:07:19]Then in case of recurrent UTIs or UTI episodes, more than two episodes in 3 months.

[00:07:25]Uh so, we have to ask the patient if there is any recent catheterization history is there for the patient. And then any previous culture reports, if available, we can do uh change the antibiotics as per that also.

[00:07:37]>> Okay.

[00:07:38]>> Then in IDSA guidelines, classification mainly complicated and uncomplicated UTI. Uncomplicated UTI is infection confined to the bladder in an afebrile woman or a man. In case of complicated UTI, infection is beyond the bladder.

[00:07:52]That is it causes pyelonephritis. It can cause a febrile illness. Then catheter associated UTI, prostatitis.

[00:08:00]Then Complicated UTI classification, it is accompanied by symptoms which suggest an infection extending beyond the bladder which including fever, then flank pain, costovertebral angle tenderness, then pyelonephritis in complicated, then UTI with systemic symptoms associated with transurethral, suprapubic, or intermittent catheterization is encompassed in complicated UTI.

[00:08:27]>> Suprapubic catheterization is done when which condition? Emergency room.

[00:08:33]>> Obstruction.

[00:08:34]>> Obstruction.

[00:08:35]>> You know, only done in obstruction in emergency room. There are some other conditions which will be done by urologist.

[00:08:41]>> Okay. Then doses, amoxicillin and clavulanic acid can be given given as a dose of 875 mg to 125 mg.

[00:08:50]>> Where it is classically given? Which type of UTI we give amoxicillin or amoxicillin clavulanic acid?

[00:08:56]>> Oh.

[00:08:57]Um.

[00:08:58]Gram positive. Positive.

[00:09:00]>> It covers both gram positive and also gram negative. Classically we give in pregnant ladies. For some other conditions we can give quinolones. But here we give like Augmentin or amoxicillin in pregnant ladies. When you are admitting you are giving ceftriaxone.

[00:09:17]>> Then cefixime can be given as a dose of 400 mg OD.

[00:09:21]>> Cefixime.

[00:09:22]>> Cefixime.

[00:09:23]>> Okay. 400 mg OD or commonly available 200 mg.

[00:09:26]>> 200 BD.

[00:09:27]Then cefuroxime can be given as 500 mg BD dose.

[00:09:31]>> Okay.

[00:09:32]>> This This female patient was admitted under general medicine and she was discharged after 5 days of treatment.

[00:09:38]>> Okay.

[00:09:40]This patient had recurrent episodes or >> No, this was the first episode.

[00:09:43]>> First episode of how many days you have to treat?

[00:09:46]>> 3 to 5 days.

[00:09:47]>> 5 days is enough.

[00:09:48]It is repeated episodes or complicated UTI with structural complications, structural defect. Then you have to give for 14 days. Here it is 5 to 7 days is more than sufficient.

[00:09:59]Okay.

[00:10:00]>> Okay.

[00:10:00]>> Thank you.

[00:10:01]>> Thank you, sir.